What Are the Requirements to Have Insurance Cover Blepharoplasty?

Excess upper eyelid skin runs in both sides of my family, and most have impaired vision by their late 50s. At 37, my upper eyelids hang over my lashes; the excess skin is about 1/2" when pinched with no apparent fat, just skin sagging over lashes. I'm used to it, but there is definitely an upper black line in my vision where the lids are pressing down, and I can "see" my lashes at all times.

What are the usual requirements to gain insurance approval with a good PPO? Is this even possible, or is it always considered cosmetic?

Doctor Answers 64

Insurance coverage of blepharoplasty

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Most insurance companies will cover blepharoplasty if 3 requirements are met.

1. Documented photo of eyelid droop or dermatochlasia (excess skin above the eyelid)

2. Documented clinical exam by a physician

3. Improvement in superior visual field test with tape compared to without. (Basically you have to see better to make it a non cosmetic case)

Insurance companies never cover the lower eyelid blepharoplasty

Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 50 reviews

The Visual Field Test tells all

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It would be very unusual at your age to have an insurable amount of visual field obstruction, but not impossible. The Visual Field Tests are simple tests that have to be done by an ophthalmologist, not by a plastic surgeon.

If you have an ophthalmologist, they can arrange for you to have it done and then you can see if you are insurable. Expect major resistance from your carrier, however, as they will likely be skeptical of your "medical necessity" for an upper blepharoplasty.

Fortunately, the costs of upper lid surgery are among the lowest of all facial cosmetic surgeries and the results are great!

If vision is impaired by excess eyelid skin, then yes, procedure 15823

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If the excess eyelid skin is pushing down your eyelids and your vision is impaired, then insurance may help cover the costs.

The definitive test required by the insurance companies is the visual field exam - taped and untaped. You'll look at some flashing lights and push a button when you see the light. Then you'll repeat the test after having your eyelids taped up. The computer records how many you saw and how many you missed. It also keeps track of false positives and negatives, so it doesn't help to cheat.

If the test shows that your vision in the upper fields have improved by have your eyelid skin removed from your field of view, then insurance will likely cover it. Unless it's medicare, they may also require preop photos and a letter of medical necessity submitted to them for prior authorization before surgery.

Of course, all of this depends on your insurance coverage. Contact your insurance company to make sure that its not excluded from your policy. The procedure code is 15823. If it is covered, you'll still be responsible for meeting your deductible and co-pays, based on your coverage.

Jonathan Hoenig, MD
Beverly Hills Oculoplastic Surgeon

Field Test

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In most cases, insurance does not cover eyelid surgery. Removal of simple excess skin and fat from the upper and lower eyelids is considered "cosmetic" in most cases, where the goal is primarily improvement of appearance.

In select cases, where the upper eyelid skin hangs so far over the upper eyelid lash margin that this extra "hood" of skin actually blocks the peripheral vision, upper eyelid surgery should be a covered benefit of your insurance plan. In these cases, the upper eyelid surgery is performed for functional improvement, and therefore is "reconstructive" and not cosmetic in nature. It is important that your surgeon properly documents the medical necessity of the planned procedure with your insurance carrier before the procedure is done. Most commonly, this involves sending you to an optometrist or ophthalmologist to have computerized visual field testing, which documents the degree to which your hanging upper eyelids obscure the peripheral vision. The test is then repeated with your excess upper eyelid skin temporarily taped up in a higher (non-obstructing) position to show the improvement of your peripheral vision that should be expected following blepharoplasty for the upper eyelids.

Drooping of the brow and forehead may also contribute to the visual field obstruction, and your plastic surgeon should evaluate whether brow lift (in addition to, or in place of, upper blepharoplasty) is the proper treatment option for you.

Although most insurance carriers will make every effort to deny benefits even for legitimate functional surgery such as this, proper documentation and diagnostic studies will tip the balance in your favor, and your insurance carrier should cover at least a portion of the cost of the operation.

Athleo Louis Cambre, MD
Los Angeles Plastic Surgeon
5.0 out of 5 stars 6 reviews

Insurance Blepharoplasty

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In order to qualify for an insurance blepharoplasty, you have to have impairment of your visual field.  An ophthalmologist can administer this visual field test.  If you have significant impairment, your insurance will often cover the blepharoplasty.

Gilbert Lee, MD
San Diego Plastic Surgeon
4.6 out of 5 stars 25 reviews

Requirements for medical coverage for bleph

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In order to get an upper bleph covered you must not only have visual symptoms but visual disability.  The insurance companies have become more strict over the years. An ophthalmology exam must be performed and visual field testing must document severe field loss superiorly. In general the skin must be hanging over the lashes almost to the center of the pupil, the black in the center of your eye. The insurance companies require a photo to document the severity.

Katrinka L. Heher, MD
Boston Oculoplastic Surgeon
5.0 out of 5 stars 8 reviews

Insurance coverage of eyelid surgery

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In order for insurance companies to consider paying for eyelid surgery, they need to be convinced that the surgery is medically necessary, not just cosmetically necessary. To achieve that, we can submit a letter stating medical necessity based on salient parts of the exam, as well as high quality photographs that illustrate the problem areas to the reviewer. In addition, we will perform peripheral vision testing to demonstrate that the peripheral vision is improved with the lids raised. Ultimately, it is the decision of the patient's insurance company whether they chose to pay for the procedure we are recommending. 

Michael Loeffler, MD
Pompano Beach Oculoplastic Surgeon

What Are the Requirements to Have Insurance Cover Blepharoplasty?

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Insurance companies often will cover upper lid surgery if the patient has skin resting on the eyelashes and improvement in the visual field examination when the upper lid is taped.  The results of the visual field exam plus photographs are sent to the insurance reviewer ahead of time to determine coverage. 

Requirements to have insurance cover an upper blepharoplasty

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 It is best to check with your insurance booklet that comes with her insurance policy which spells out covered benefits.
 For an insurance company to cover an upper blepharoplasty they're usually has to be a significant restriction of visual fields(25-30%) before they will consider it is a covered medical benefit for medical necessity.
 A visual field obstruction test( taped in and taped upper lids) along with photographs and chart notes from your surgeon are submitted to the insurance company for preauthorization prior to the surgery.
 For many examples of eyelid surgery, please see link below

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

When Insurance Covers Eyelid Surgery

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There are three basic conditions when insurance carriers will consider coverage for eyelid surgery:

1. A drooping of the eyelid which is caused by injury or merely a congenital condition.(eyelid ptosis)

2.A sagging of the lower lid (ectropian), which causes excessive tearing and eye irritation.

3.The most common condition when insurance considers coverage is when there is a significant drooping of the upper eyelid skin causing a partial obstruction in vision.

To get coverage for #3 the following steps must occur: 1. An examination by the physician 2. A visual fields test to ascertain the degree of visual obstruction 3. A letter seeking prior authorization for the removal of the excess skin, submitted by your surgeon.

Joseph Rucker, MD, FACS
Eau Claire Plastic Surgeon
4.7 out of 5 stars 22 reviews

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.