Will I Qualify for Insurance Coverage on a Blepharoplasty Procedure? (photo)

I am 23 and I've had droopy eyelids for as long as I can remember and it just seems to be getting worse. It's mainly my right eye that droops the worst and sometimes I notice that my right eyebrow is lower than my left eyebrow. Judging from my picture.. do you think it's at all possible I will qualify for insurance coverage? Would I be better off just getting botox? Thank you!

Doctor Answers 10

Will I Qualify for Insurance Coverage on a Blepharoplasty Procedure?

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Sorry to say there are so many hoops to jump through and additional out of pocket expenses that it may not be worth the effort. First which health insurance plan do you have? HMO or EPO or PPO, are there restrictions to upper lid surgery? What are you deductibles? What are you co pay numbers. Second you will need a visual fields examination, a pre determination letter, photos from the eye doctor to the insurance company. This is not usually covered by the insurance plan as to the letter and your co pays. So you most likely will be spending 50% of the costs to do the operation to try and get it approved. With that caveat the OK is very hard to obtain. Better you pay for the upper lid blepharoplasty and live your life because the time and effort it would take to TRY an obtain this coverage could be months. Good luck 

Insurance coverage for blepharoplasty

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II can't speak for other areas of the country but the NY insurers put blepharoplasty on their hit lists more than 20 years ago. Barring multiple sclerosis, a stroke, myasthenia gravis, etc., they will not cover the procedure. You do not have sufficient impairment of the visual fields. Upper lid blepharoplasty is an inexpensive, short procedure that can even be performed under local anesthesia in an office based OR. Botox will not offer you the degree of improvement that is indicated. Best wishes.

Insurance coverage is improbable.

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You do exhibit interference of the brow fold with the eyelid.  Your fold actually rests on the upper eyelid margin.  There was a time when this would be covered by insurance.  Now this is almost universally regarded as a cosmetic issue.  You are an excellent candidate for a very conservative upper blepharoplasty.  You can see examples of this type of work on my website.  The key is not removing all of the upper eyelid fold.  One only wants to remove enough of the fold to expose a uniform strip of the eyelid platform.  One should preserve essentially all of the upper eyelid fullness.  Less is more.  A microdroplet cosmetic botulinum toxin treatment also lifts the eyebrow and will reduce the heaviness of the upper eyelid fold but this only lasts a few months.  Yours is basically a surgical problem but too much upper eyelid surgery will rob you of your upper eyelid fold which is a very important aspect of your youthful appearance. 

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Insurance Coverage for Upper Eyelid Blepharoplasty

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Insurance companies have placed upper eyelid surgery squarely in the automatic challenge list.  The pre-approval process has become so onerous for the Physician that it has become very hard to justify use of resources for this category of treatment. At age 23, you face a Herculean task in getting your procedure approved.  Botox is a wonderful option in chemically raising the brow, but requires ongoing maintenance.

Stephen Prendiville, MD
Fort Myers Facial Plastic Surgeon
4.9 out of 5 stars 104 reviews

Medical qualifications for a blepharoplasty

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 Each insurance company has different criteria for medical coverage related to a blepharoplasty.  To qualify for an insurance company to pay for a medically related blepharoplasty, a consultation, physical examination, photographs, and visual field obstruction tests need to be submitted to your insurance company. The insurance company  will then preThe-authorize the procedure or not. Most insurance companies require at least 30% of your entire field of vision to be obstructed  from the excess skin on the upper lid to considered  for it to be medically related.

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 158 reviews

Eyelid surgery vs botox

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Hello. Based on your photo, it looks like there is some excess skin on your upper eyelids, but not enough where you would qualify for insurance coverage for surgery. That being said, if you dont like the appearance of your eyes, upper eyelid surgery is probably the best option for you. Botox may help lift the brow a little, but I suspect you would only notice a modest improvement. A conservative upper blepharoplasty would give you a "platform" to wear eye makeup and reduce the tired look caused by the excess skin.

Mitesh Kapadia, MD, PhD
Boston Oculoplastic Surgeon
4.9 out of 5 stars 182 reviews

Insurance coverage

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Unless it's for health reasons, insurance doesn't usually cover eyelid surgery since it's considered cosmetic. However,you may be able to get it covered if your vision is impaired. This needs confirmation through a vision test.

Will Insurance Cover My Blepharoplasty?

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Insurance companies realize that many patients seek blepharoplasty surgery for cosmetic reasons.  As such, the criteria for insurance coverage of a blepharoplasty are quite stringent.  Insurance companies evaluate the amount of blockage of your visual field (determined by visual field testing) and the amount of blockage of your visual axis demonstrated by photography.  You can try to consult an oculoplastic surgeon, but based on your photos I feel it is very unlikely that any insurance company would cover your blehparoplasty.

Michael McCracken, MD
Lone Tree Oculoplastic Surgeon

Will I Qualify for Insurance Coverage on a Blepharoplasty Procedure?

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It is possible that blepharoplasty might be a covered benefit. It depends upon your insurance carrier's criteria. To make that determination you will need to consult with a Facial Plastic Surgeon or Oculoplastic Surgeon and have visual field testing. Notes, photos and the test results will be reviewed by your insurance carrier to determine whether blepharoplasty would be covered or would be out of pocket. I hope this information is helpful.

Stephen Weber MD, FACS

Lone Tree, Colorado

Insurance can Cover Upper Eyelid Surgery

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Excess upper eyelid skin can effect vision and when it does, an upper lid blepharoplasty may be covered by insurance.  Different insurance policies have different coverage criteria.  In Naples, Florida, most insurance plans require a Visual Field test and photos of the patient.  The Visual Field Test examines what the eye can see and determines if the excess upper eyelid skin adversely effects vision.  With photos, the eyelids resting on the eyelashes also suggest that vision may be impaired by the excess skin.

Jonathan Sonne, MD
Naples Facial Plastic Surgeon

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.