insurance covers for eyelid surgery?
Will my Insurance Pay for Blepharoplasty?
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Doctor Answers 45
Insurance Payment for Blepharoplasty Requires Decrease in Vision Proven by Visual Fields
Most Bleparoplasties that are done are not covered by Medical Insurance. Insurance companies have strict criteria that must be met for Insurance to cover a Blepharoplasty.
To meet these criteria you must have a Visual Field Exam done usually by an Optometrist.
That exam tests your ability to see around you. If the Visual Field Test shows that 25% of your upper Visual Field is cut or lost by the overhanging Upper Eyelid Skin then your Blepharoplasty may be covered
Insurance can pay for Blepharoplasty in certain cases
If hooding of the upper eyelids interfere with your vision, your health insurance company may cover blepharoplasty surgery for the upper eyelids only. Most health insurance companies exclude coverage for cosmetic surgical operations such as the lower eyelid blepharoplasty or any complications that might occur from the surgery. Most insurance plans exclude coverage from secondary or revisionary surgery.
BLEPHAROPLASTY AND INSURANCE
In some instances insurance will cover the fee for upper eyelid blepharoplasty. The reasons include:
1- Significant interference with vision or obstruction of the superior or lateral (outer) visual fields; insurance companies and Medicare will usually require visual field testing to document a minimum of 12 degrees or 30 percent loss of upper field of vision.
2-Difficulty reading due to superior visual field loss.
3- Looking through the eyelashes or seeing the upper eyelid skin.
Insurance companies other than Medicare will require the visual fields and photographs be submitted for review and pre-approval prior to surgery.
Lower eyelid blepharoplasty is never covered by insurance- this is a purely cosmetic and not a functional (medically indicated) procedure.
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Functional blepharoplasty be covered by insurance
Third party payers will not pay for a cosmetic blepharoplasty. However, some patients may exhibit visual field obstruction documented by a visual field test in the upper eyelids. These patients may qualify for a functional blepharoplasty to relieve the obstruction.
Depends on visual field obstruction
To obtain insurance coverage for an upper blepharoplasty there are several items that are submitted to insurance to document medical necessity. These are visual field obstruction test( taped and untaped), photographs of the eyelids and your surgeon's chart notes. If there is approximately 25-30% of visual field obstruction of the entire field of view, some insurance companies may consider paying for this as a functional problem and consider it medical necessity. Patient's are still required to pay the co-pays and deductibles according to their insurance plan, even if it's covered under insurance. Always be prepared to pay for this surgery in case your insurance denies the claim. Lower blepharoplasty is considered cosmetic. for many examples of eyelid surgery, please see the link below
Blepharoplasty is usually not covered.
That is a good question and one that almost every patient asks. However, the insurance companies are very strict when it comes to covering procedures which may seem "cosmetic" in nature. Your best hope of getting it covered by insurance is to have a visual field test by an ophthalmologist. However, the test will have to show significant visual obstruction of your vision by your redundant upper lid skin for the insurance company to consider covering the procedure. Then, even if they do cover it, you would need to find a plastic surgeon who takes your insurance. Since, the insurance companies usually only pay pennies on the dollar, most plastic surgeons do not take insurance.
I hope this is helpful.
David Shafer, MD
Shafer Plastic Surgery, NYC
Visual Field Test
Insurance coverage for Blepharoplasty is limited to those patients whose excess upper eyelid skin or sagging brow causes a measurable impairment of their peripheral vision. This condition must be documented by Visual Field testing, which evaluates the degree of obstruction caused by the hanging upper eyelid or sagging brow. One measurement is done with the eyelids in the "normal" position, and a second measurement is done with the eyelids taped or held open. If there is measurable improvement, insurance may cover the procedure, but there are generally no guarantees.
Decrease in visual field may justify upper blepharoplasty
If the upper eye lid covers the pupil, there is infection due to excess folds of skin, or an eye doctor can demonstrate decrease in visual field due to heaviness of the upper lid, insurance may cover various surgeries on the upper lid depending if the problem is excess skin, weak or detached levator muscle, or ptosis of the brow causing visual field deficit. If your visual field is normal and you have no dermatological condition, blepharoplasty will not be covered.
Will insurance cover my blepharoplasty
If the skin of your eyelids is resting over the lashes, and or interfering with your peripheral vision, a blepharoplasty can be considered medically indicated and covered by insurance.
Insurance May Cover Blepharoplasty to Correct Vision
You will have to check with your carrier to get an answer to this question, but generally insurance does not cover plastic surgery unless it is performed for medical reasons. In the case of blepharoplasty, some patients experience such significant drooping of their upper eyelid that it actually impairs their vision. As mentioned by my colleagues above, an optometrist would need to evaluate your case and you may need to provide additional proof of medical need to your insurer before you can be cleared. I hope this helps.
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.