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.