Eyelid surgery is a frequent procedure used to improve the appearance of the face. The technique removes extra skin and fat from the top eyelids, giving the eyes a more youthful appearance. Loose skin and tissue on the lower eyelids can also cause puffy bags under the eyes, which can be removed with eyelid surgery. Eyelid surgery is deemed elective when performed exclusively for cosmetic purposes, and hence is not covered by medical insurance.
Medical insurance may cover eyelid surgery if it is judged medically essential. Heavy skin that hangs over the lash line and obstructs vision is removed with functional eyelid surgery. Excess, hanging upper eyelid skin can obstruct eyesight, making it harder to do things like drive, read, or send text messages.
In order to assess coverage for eyelid surgery, most insurance companies require proof in the form of a vision test. A board-certified eye doctor, such as an oculoplastic surgeon, must perform the vision test. If the vision test reveals that the patient has a vision problem, the surgeon takes photographs of the problem and sends them to the patient’s insurance company. The patient’s unique coverage plan determines whether the insurance company covers all or part of the cost of eyelid surgery.
What is the criteria for insurance to pay for eyelid surgery?
Insurance companies will only cover the surgery if it is classified for reconstructive or functional problems like ptosis (eyelid drooping due to muscle weakness or nerve damage), blepharochalasis (eyelid swelling), dermatochalasis (excess skin), herniated orbital fat (excess fat), floppy eyelid syndrome, and visual field obstruction, according to the American Society of Plastic Surgeons.
- You must first schedule a consultation with your optometrist to establish your requirements. Make a note of the requirement for surgery. Any of the following concerns must be documented by your doctor to establish that blepharoplasty is medically necessary:
- Orbicularis oculi hypertrophy (enlargement) (muscles that work the eyelids)
- Request that a surgeon take images of the issue that requires treatment. Patients will be required to sign a release form if an insurance company requests to see the photos.
- Get all of the pre-operative diagnostic tests that your doctors recommend. These may include the following:
Are droopy eyelids covered by insurance?
Ptosis surgery is generally not covered by insurance companies. However, if your ptosis is severe enough that your eyelids are obstructing your vision and affecting your everyday activities, insurance reimbursement may be available. If your drooping upper eyelids are obstructing your vision to the point where it is affecting your life, ptosis surgery may be considered medically required and reimbursed by insurance.
Certain factors may be used by insurance companies to decide if ptosis surgery is medically necessary. They usually require the following details:
Notes from your doctor. The position of the eyelids and the patient’s complaint about the ptosis interfering with specific everyday activities must be properly documented in these notes (driving, reading, etc.).
Images of the Eyelids and Eyes. The eyelids or excess eyelid skin obstructing the line of sight, specifically falling within less than 2 millimeters of the center of the pupil, must be clearly visible in frontal and side images.
Visual Field Examination. This non-invasive test is commonly performed in an eye doctor’s office to examine peripheral vision. Both with the eyelids in their natural position and with them held up, the visual field is examined (usually with special tape). The contrast between the taped and un-taped visual fields can reveal how much vision is compromised and whether or not ptosis surgery will be covered by insurance.
Insurance companies will occasionally agree to cover ptosis surgery if there are other factors. Some of these indications include reconstruction following thyroid eye illness, congenital ptosis, and persistent dermatitis caused by skin rubbing on the eyelashes.
If you’re thinking about ptosis surgery and want to know if your insurance will cover it, it’s usually simple to find out. Simply inquire with your insurance company about whether or not your surgery is covered by your plan, and if so, what proportion.
Before making any coverage assumptions, always check with your health insurer. It can be difficult to tell what is medically necessary and what is merely optional in many circumstances.
Does insurance cover upper blepharoplasty?
Though the requirements are stringent, you may be eligible for insurance coverage for upper eyelid surgery if the eyelid is obstructing your vision severely. Blepharoplasty is no longer regarded cosmetic in cases of severe drooping or ptosis, but rather a medical necessity.
Who determines if you need eyelid surgery?
Only a doctor can diagnose your medical problems and determine whether surgery is necessary. In these areas, an ophthalmologist, optometrist, or plastic surgeon would be the most knowledgeable. Your doctor will be able to determine whether surgery or other treatments are the best option for you.
When is an eyelid lift medically necessary?
When the upper-eyelid skin droops down to the point where it blocks vision, commonly in the superior visual fields, an upper-eyelid blepharoplasty is regarded medically required.
When there is a lot of excess upper-eyelid skin, it can hang down and create a curtain effect on vision when you look up.
There are a variety of different disorders that can cause the top eyelid to hang down over the eye, causing visual loss.
This occurs as a result of a weakening in the tiny muscle that lifts the top eyelid. Upper-eyelid ptosis is the medical term for this disorder. Separate operations can be done in conjunction with an upper eyelid blepharoplasty to help elevate the eyelid and relieve vision restriction.
Is it worth getting eyelid surgery?
Yes, most people feel that their upper blepharoplasty was worth the money and time it took to recuperate, and eyelid surgery has a “Worth It” rating of 95 percent on RealSelf. Patients give the following reasons for their satisfaction with the procedure:
- Upper blepharoplasty is a treatment that is quite inexpensive. When compared to, say, a facelift, the cost of the operation is in the middle.
- The operation improves the appearance in a significant and noticeable way. Patients appear more alert, open, and vibrant, and they can see the consequences in the mirror every time they catch a glimpse of themselves.
Finding a highly experienced plastic surgeon is crucial for optimal results. For a visually acceptable result and a safe operation, the eye area is particularly delicate and necessitates a sophisticated approach.
Does insurance pay for eye lift?
“Does insurance cover blepharoplasty?” is one of the most often asked queries by my patients. “Will my insurance cover eyelid surgery?” or “Will my insurance cover eyelid surgery?”
This is a fantastic question. The majority of insurance companies have strict criteria for funding eyelid surgery. I’ll try to keep this essay focused on the insurance requirements for blepharoplasty and/or ptosis correction. While there may be minor discrepancies between carriers, most insurance firms use Medicare requirements to determine eligibility.
In general, insurance companies will cover blepharoplasty or ptosis restoration if the eyelids impede the upper visual field in a “visually significant” way that “affects activities of daily living.” To put it another way, blepharoplasty or ptosis correction is considered medically necessary and may be reimbursed by insurance if the upper lids impede enough of your vision to seriously disrupt your life.
So, what criteria do insurance companies employ to decide if blepharoplasty, or upper eyelid surgery, is “visually significant” and thus covered? They require three pieces of information:
1) Medical records. The location of the lids, a decreased visual field, and a patient complaint about the upper lids interfering with particular activities must all be documented in these notes (driving, reading, etc). Standard oculoplastic measurement procedures should be used to determine whether the lid or extra skin reaches within 2 millimeters of the pupil (also called an MDR1 less than 2mm).
2) Ophthalmic photography from the outside. These are essentially high-resolution photographs of the eyelids and eyes. To meet the criterion, the eyelids or extra eyelid skin must be visible to be less than 2 millimeters from the center of the pupil. Frontal and side pictures must be clear.
Visual Fields are the third type of visual field. A visual field test is a noninvasive procedure for assessing peripheral vision. At most cases, this test is done in an ophthalmologist office. Both with the eyelids in their natural position and with them held up, the field of vision is assessed (usually with tape). Insurance coverage for upper eyelid surgery is determined by the difference between the taped and untaped visual fields. Depending on the insurance company, the vision field must improve by a specified percentage or number of degrees.
Other indications may be accepted by insurance companies to fund upper eyelid surgery on occasion. Some of these reasons include reconstruction after thyroid eye illness, children born with ptosis (congenital ptosis), and persistent dermatitis owing to skin rubbing on the eyelashes.
Once an oculoplastic surgeon receives all of the essential information, they will assess it and decide whether upper eyelid surgery is medically necessary.
If you answered yes, the next step is to provide the insurance company all of your notes and testing results. Following that, the carrier will either “pre-authorize” or “deny” the claim. A pre-authorization indicates that the insurance company recognizes that blepharoplasty or ptosis correction is medically essential and that they intend to cover the procedure. A pre-authorization is reassuring, but it is not a 100 percent assurance of coverage. Insurance companies may do a second evaluation of the case after the procedure has been completed. The carrier may occasionally dispute the original pre-authorization and consider the procedure cosmetic, which is exceptional. If this happens, an appeal can be filed; however, if the claim is denied again, the patient is normally responsible for payment.
Medicare operates in a unique way. Nothing is pre-authorized by Medicare (any procedure- not just eyelid surgery). Medicare, on the other hand, has well defined criteria that most oculoplastic doctors are well-versed in. It can be established whether Medicare would cover a patient’s eyelid surgery based on the exam and tests. While most oculoplastic surgeons are correct in their coverage assessments, because Medicare does not pre-authorize surgery, the patient must fill out and sign a “ABN” form. While the surgeon feels Medicare will reimburse the blepharoplasty or ptosis correction, the ABN usually stipulates that the patient is responsible for the payment if the claim is denied. Most oculoplastic doctors will be able to tell you whether or not blepharoplasty or eyelid surgery will be covered by Medicare or an insurance provider.
How much does it cost to have eyelid surgery?
According to 2020 figures from the American Society of Plastic Surgeons, the average cost of cosmetic eyelid surgery is $4,120. This is only a portion of the entire cost; it excludes anesthesia, operating room facilities, and other related costs.
How long does it take for upper eyelid surgery to heal?
After eyelid surgery, most people return to their typical activities in 10-14 days, but you should plan on taking some time off to allow your eyelids to heal. Covering your key obligations ahead of time is a fantastic approach to speed up your recovery.
It’s critical to clear your schedule so you can focus on relaxing, whether you need to stock the pantry with easy-to-prepare items or ask a friend to drive your children to their activities.