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 eyelid surgery?
Blepharoplasty, blepharoptosis repair, and brow lift operations are all included in this text. Blepharoplasty is a surgical technique that removes excess tissues (skin, muscle, or fat) from the upper and/or lower eyelids. Blepharoptosis is a condition in which the lower eyelid droops below its usual position. The goal of brow lift surgery is to return the brow to its natural anatomic position. These operations can be used for cosmetic as well as utilitarian reasons. Depending on the etiology of the visual field loss, a blepharoplasty and/or blepharoptosis repair OR a brow lift procedure is usually required to correct functional superior visual field restriction. Combined procedures must meet the individual criteria for each procedure in circumstances where they are sought.
Procedures are considered medically necessary in this article if there is a severe functional impairment AND the procedure can be reasonably expected to improve that impairment.
Procedures are considered reconstructive in this article when they are designed to rectify a major deviation from normal due to an accident, disease, trauma, or treatment of a disease or congenital condition.
Note: Benefits for reconstructive services as outlined by this document are not included in all benefit contracts. This document is superseded by benefit language.
Procedures are deemed cosmetic in this article when they are designed to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are sometimes defined as those whose primary goal is to maintain or improve one’s looks.
When BOTH of the following criteria are met, upper eyelid blepharoplasty or blepharoptosis repair is considered medically necessary:
- The goal of intervention is to relieve central vision obstruction that is significant enough to cause occlusion amblyopia in the opinion of the treating physician.
For ANY of the following disorders, upper eyelid blepharoplasty or blepharoptosis correction is considered medically necessary:
Note: When a patient requests a combination surgery (for example, blepharoplasty and brow lift), the patient must complete the requirements for each procedure separately.
When ALL of the following conditions are met, unilateral or bilateral upper eyelid blepharoplasty is considered medically required to remove impairment of central vision:
- Complaints of upper eyelid skin drooping, looking through the eyelashes, or seeing the upper eyelid skin producing considerable functional impact, such as trouble reading or driving as a result of upper eyelid skin sagging, looking through the eyelashes, or seeing the upper eyelid skin; and
- Either there is excess skin overhanging the upper eyelid edge and resting on the eyelashes, or there is considerable dermatitis on the upper eyelid due to redundant tissue. Photographs from the front and side (or sides) of the surgery must be taken with the camera at eye level and the individual gazing straight ahead (primary gaze); and
- The superior visual field is a) less than or equal to 20 degrees or b) there is a 30% reduction of upper field of vision compared to normal prior to manual elevation of redundant upper eyelid skin (taping); and
- Upper visual field measurements are restored to within normal limits after manual elevation (taping) of the redundant upper eyelid skin.
When ALL of the following criteria are met, blepharoptosis correction is considered medically required to remove blockage of central vision:
- Complaints about eyelid position interfering with vision or visual field-related activities, such as trouble reading or driving; and
- Photographs showing the subject staring straight ahead with the camera at eye level, with documentation of the atypical lid position (pictures should be submitted for examination); and
- The superior visual field is a) less than or equal to 20 degrees, b) there is a 30% loss of upper field of vision compared to normal, or c) the margin reflex distance between the pupillary light reflex and the upper eyelid skin edge is less than or equal to 2.0 mm prior to manual elevation of the upper eyelid and redundant upper eyelid skin (taping); and
- Upper visual field measurements are restored to within normal limits after manual elevation (taping) of the upper eyelid and redundant upper eyelid skin.
When ALL of the following conditions are met, a brow lift (that is, the repair of brow ptosis caused by laxity of the forehead muscles) is considered medically necessary:
- Brow ptosis results in a functional impairment of the upper/outer visual fields, as evidenced by recorded complaints of vision or visual field-related activities such as difficulties reading due to upper eyelid drooping, looking through the eyelashes, or seeing the upper eyelid skin; and
- AJ Aldave, M Maus, and PA Rubin. Advances in the treatment of retraction of the lower eyelids. Facial Plast Surg, 15(3), 213-224, 1999.
- Facial Plast Surg. 1999; 15(3):173-178. Castro E, Foster JA. Upper lid blepharoplasty. Facial Plast Surg. 1999; 15(3):173-178.
- Ptosis evaluation and management. Otolaryngol Clin North Am. 2005; 38(5):921-946. Edmonson BC, Wulc AE.
- Correlation between vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery, Federici TJ, Meyer DR, Lininger LL. Ophthalmology, 106(9), 1705-1712, 1999.
- Thyroid orbitopathy. Aust Fam Physician. 2003; 32(8):615-620. Fung S, Malhotra R, Selva D.
- Comprehensive care of brow and forehead ptosis, Hoenig JA. 2005; 38(5):947-984 in Otolaryngol Clin North Am.
- Blepharoplasty: an overview, Karesh JW. 87-109 in Atlas Oral Maxillofac Surg Clin North Am, 1998.
- F. Mellington and R. Khooshabeh. Are we measuring the appropriate thing when it comes to brow ptosis? The influence of surgery and the relationship between objective and subjective measures of quality-of-life improvement after surgery. 26(7):997-1003 in Eye (Lond).
- Quantitating the superior visual field loss associated with ptosis. Meyer DR, Linberg JV, Powell SR, Odom JV. 107(6):840-843 in Arch Ophthalmol, 1989.
- Evaluating the visual field consequences of blepharoptosis using automated static perimetry, Meyer DR, Stern JH, Jarvis JM, Lininger LL. Ophthalmology, vol. 100, no. 5, 1993, pp. 651-658.
- JB Mullins, JB Holds, GH Branham, JR Thomas A evaluation of 400 cases of complications associated with the transconjunctival technique. 385-388 in Arch Otolaryngol Head Neck Surg, 1997.
- Surgical therapy of essential blepharospasm, Patel BC. Otolaryngology Clinics of North America, 38(5), 1075-1098, 2005.
- Lower lid blepharoplasty: an examination of indications and the treatment of 100 patients. Rizk SS, Matarasso A. 111(3):1299-1306 in Plast Reconstruc Surg, 2003.
- Textbook of Surgery: The Biological Basis of Modern Surgical Practice, Sabiston DC Jr. pp. 1326 & 1327, W.B. Saunders, Co., Philadelphia, 1997, 15th ed.
- PJ Sakol, G Mannor, and BM Massaro. Blepharoptosis can be congenital or acquired. Curr Opin Ophthalmol, 10(5), 335-339, 1999.
- Eyelid metrics. Ophthal Plast Reconstr Surg. 2004; 20(4):266-267. Small RG, Meyer DR.
- The measurement and definition of ptosis. Small RG, Sabates NR, Burrows D. 1989; 5(3):171-175. Ophthal Plast Reconstr Surg
- Upper lid blepharoplasty. Facial Plastic Surg. 2013; 29(01):16-21. Weissman, J., and Most, S.
Review by the Medical Policy and Technology Assessment Committee (MPTAC). In the MN section, there has been a minor formatting change. The sections “Description” and “References” have been revised.
Review of the MPTAC. The sections on discussion, general information, and references have been revised. Additional diagnosis code examples have been added to the Coding section, which has been reformatted.
H57.811-H57.819.h57.811-H57.819.h57.811-H57.819.h57.811-H57.819.h57.811-H57.819.h57.811-H57.819.h
Review of the MPTAC. “Current Effective Date” was changed to “Publish Date” in the document header. The documentation with images requirement for blepharoptosis has been clarified. Discussion/General Information and References sections have been updated.
Review of the MPTAC. Blepharoplasty standards for vision or visual field-related tasks have been clarified. Definitions and references have been updated.
Review of the MPTAC. A medically required statement is denoted by a defined shorthand in the brow lift. References have been updated. ICD-9 codes have been removed from the Coding section.
Review of the MPTAC. To clarify visual field standards, the medically essential parameters for blepharoplasty and blepharoptosis correction were revised. The Reference section has been updated.
Review of the MPTAC. In the medically necessary portion for Blepharoptosis Repair, the criteria language has been clarified.
Review of the MPTAC. In the Blepharoplasty and Blepharoptosis sections, age-related criteria were removed. Medically required visual field requirements for blepharoplasty and blepharoptosis are now voluntary rather than mandatory. For the medically required areas of blepharoplasty and blepharoptosis, added Margin Reflex Distance (MRD) as an option. The Reference section has been updated.
Review of the MPTAC. Visual fields must be submitted, it has been clarified. Reconstructive statement and definitions have been added. Nerve palsy has been clarified as a separate indication. To emphasize that not all benefit contracts contain a reconstructive services benefit, a remark was included following the Reconstructive definition. References have been updated. “Cosmetic and not medically required” was added to the phrase “cosmetic.” At the MPTAC meeting on November 29, 2007, this amendment was approved.
Review of the MPTAC. Blepharoplasty, blepharoptosis, and brow lift medically necessary requirements have been specified. The section on General Information has been revised.
Review of the MPTAC. Adult visual field standards have been clarified. Language about blepharoplasty in youngsters has been added. Blepharoplasty of the lower lids was included as a cosmetic procedure. The coding has been updated.
Review of the MPTAC. Pre-merger Anthem and Pre-merger WellPoint Harmonization were used to make this revision.
Does insurance ever cover blepharoplasty?
“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.
When is a blepharoplasty 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.
How do you qualify for blepharoplasty?
To indicate potential correction by the suggested method or procedures, a minimum 12 degree OR 30% loss of upper field of vision with upper lid skin and/or upper lid margin in repose and elevated (by tape of the lid) is necessary.
Can I use my HSA for blepharoplasty?
In cases of medical necessity, health insurance may pay all or part of the surgery costs, but you must first undergo visual field testing by an eye care professional and meet certain criteria.
You can utilize funds deducted from your salary to cover all or part of your eyelid surgery if you have a Flexible Spending Account (FSA) or a Health Savings Account (HSA).
Can hooded eyes be fixed?
Is it possible to correct hooded eyelids? Hooded eyelids, which occur when extra skin sags and folds down from below the brow bone, can be treated with a blepharoplasty treatment. Excess skin and fat are removed, and the muscles and tissue of the eyelid are tightened.
How much does it cost to have eye bags removed?
Lower lid blepharoplasty, often known as lower eyelid surgery, is a technique that improves the sagging, baggy, or wrinkled appearance of the undereye area.
This operation is sometimes combined with others, such as a facelift, brow lift, or upper eyelid lift.
What is excess eyelid skin called?
The term dermatochalasis refers to the presence of loose and superfluous eyelid skin. It is a frequent periocular aging indication that can be noticed in both middle-aged and elderly adults. Dermatochalasis can affect the lower eyelids as well, albeit it is more noticeable in the upper eyelids. It is frequently linked with steatoblepharon, or orbital fat herniation, and blepharoptosis, or drooping of the eyelids. There may also be an unclear, low or double eyelid crease.
What causes hooded eyelids?
Hooded eyelids are typically the result of a number of age-related changes in the eyelid skin, eyebrow, underlying fat, muscle, and bone. The hooded look can hide underlying floppy eyelids (eyelid ptosis) and a droopy eyebrow, which exaggerates the hooded look. In addition to the hooded eyelid, your Plastic Surgeon should undertake a full clinical assessment during your consultation to establish if you have a drooping eyelid, a droopy eyebrow, or both.
Why is the eyebrow position an important consideration in surgery for hooded eyelids?
Because the eyebrow and upper eyelid are linked, age-related changes in the eyebrow, such as eyebrow descent or ptosis, pull down the upper lid, limiting eyelid opening and limiting the visual field. Because the outer half of the eyebrow segment has less support and gravity selectively depresses the outer eyebrow, it droops more.
Why do people choose to have surgery to correct hooded eyelids?
People who have their hooded eyelids surgically removed want their eyes to appear more open, rejuvenated, and less weary.
You would benefit from having hooded eyelid surgery if
- Excess skin, or hooding, reduces your vision field, creates heaviness in the eyelids, and produces tension headaches.
- The hooded eyelids, as well as droopy eyes, give you a worn and drowsy appearance.
Is hooded eyelid surgery classified as functional or cosmetic?
Hooded eyelid surgery is mostly functional in that it increases the visual field and alleviates problems including headaches and eye heaviness. The cosmetic benefits are clear, but secondary, because the eyelid is returned to a ‘normal and youthful’ appearance.
Is surgery for hooded eyelid covered by Medicare or private health fund
You will be eligible for Medicare and health fund coverage if a formal visual field test done by an optometrist demonstrates visual field restriction. Your Plastic Surgeon will examine your eyelid during your consultation and refer you for visual field testing. Lower eyelid surgery and eye bag surgery are considered cosmetic procedures and are therefore not covered by Medicare or private health insurance plans.
Benefits of hooded eyelid surgery
Upper eyelid surgery enhances vision, quality of life activities, productivity, and looks and offers functional, medicinal, psychological, and cosmetic benefits.
The vast majority of people considering eyelid surgery are ignorant of the functional benefits and believe it is only for cosmetic reasons.
Benefits following eyelid surgery for hooded eyelids
- Improvement in eyesight and peripheral vision, as well as facial weariness induced by ptosis-related forehead muscle compensation and hooded eyelids.
- Activities that increase one’s quality of life, such as reading and other close-work activities
- Symptoms of pain or eye strain caused by heavy and sagging lids or brows are reduced.
- Significant alleviation from tension headaches, as well as a better quality of life connected to headaches.
- Following blepharoplasty, people are assessed as looking more youthful, beautiful, energetic, and healthy, according to studies.
What results can I expect after surgery for hooded eyelids?
Eyelid surgery reduces the outward indications of aging and gives you a more youthful appearance. Although the majority of the improvements are evident right away, we recommend waiting 12 weeks for all temporary changes, such as edema, to resolve before seeing the ultimate result.
Downtime following hooded eyelid surgery
- You will be given ointment to apply to the suture line, eyedrops, ice packs, and, in certain circumstances, oral antibiotics for the first week.
- You should stay at home for the first week. If you’re going out, you should invest in an excellent pair of sunglasses. When patients go outside, they frequently complain about the glare of the sun.
- As directed by your Plastic Surgeon, you can begin scar therapy two weeks after surgery. Remember that eyelid scars heal quickly.
- Silicone gel is frequently advised, however you must be careful not to get any silicone gel into your eyes.
- Light activities are permitted for the first four weeks, after which you can resume your normal activities, including going to the gym.