When Eyelashes Are Being Pushed Downward, is Eyelid Surgery Medically Necessary?

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.

This has become a moving target.  This was once a universal criteria for medically necessary eyelid surgery.  Insurance companies have dealt with this to help reduce their liability.  In many cases, this is considered a subjective cosmetic problem and not covered.  In some cases, the insurance company has reduced reimbursement to such a low amount that surgeons may tell you that the problem is essentially not covered by your health insurance.  In some cases when considering the surgery center fees, and anesthesia costs, you might be financially better off doing this surgery as a self pay cosmetic procedure if you have high deductible insurance.

Every insurance company is different and all are becoming more difficult to deal with. Most want to see a problem  with your vision due to the excess weight and skin. Most patients describe a sense of difficulty seeing things that are above their head, as well as general eyelid fatigue and headaches. Visual field testing can confirm if there is a real problem.

For eyelid surgery to be deemed medically necessary, eyelid skin must actually touch the eyelashes or cause lash ptosis.  This is also known as dermatochalasis.  Most insurance companies require approximately 30% restriction of visual field, which must be documented by a visual field obstruction test.  Pictures will also be required.  Chart notes and preauthorization is all done prior to upper eyelid surgery.  

Some of the criteria that insurance companies are looking for are:  excessive skin weighing down the eyelids, patients having to look at their eyelids skin and/or eyelashes in primary gaze.  Recurrent skin irritation from excessive upper eyelid skin.  Marginal reflex distance; the distance from the light reflex from the camera to the lower limit of the upper eyelid margin and their results on visual field testing.

This is called "lash ptosis" when the excess upper eyelid skin pushes the eyelids and lashes downward.  In some cases, the upward gaze can be restricted however, in my over 20 years experience performing eyelid surgery this has been covered less and less by insurance companies.  If you feel that your vision is compromised, see an  eye doctor for a visual fields test.

The usual reason that insurance, including medicare , will cover a blepharoplaty is for obstruction of the visual field.  A simple test, the visual field test, can be performed at an optometrist or ophthalmologists office.  If there is enough obstruction to the visual fields, insurance usually covers the surgery.

This is a common question we get in our office.  We are always willing to submit a request to the insurance company to pay for the procedure if that is what the patient really wants.  But the insurance company has a big incentive to deny payment- it is more money in their pocket.  They have the same vague criteria we have for making the decision, and if there is any question, they will deny you.  You can always appeal their decision, and often the appeals win (especially if you have the criteria for coverage and explain why you think you meet those criteria).  They are more apt to deny coverage because they know these are cosmetic procedures, especially for anyone younger than a senior citizen.

Keep in mind insurance coverage of upper lid surgery is solely to improve vision.  It is meant for the 80 year olds who can not see the cereal on their tray in the nursing home, or who are at increased risk of falling because of a diminution in their peripheral vision.  I find most 40-50 year olds will be disappointed in the type of results they receive from insurance upper lid surgery, as they are concerned with cosmetic issues.  Those issues, such as removing bulging fat pads, the amount of skin removed, symmetry, etc. would not typically be addressed with insurance surgery.  You have to chose one or the other. 

On the other hand, if the cosmetic procedure is unaffordable, you will see some benefit from the insurance surgery.

Yoash R. Enzer, MD