“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.
Is a blepharoplasty ever 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.
What qualifies blepharoplasty?
For ANY of the following disorders, upper eyelid blepharoplasty or blepharoptosis correction is considered MEDICALLY NECESSARY: 1. Periorbital sequelae of thyroid illness; OR 2. Repair of a functional deficiency caused by trauma, tumor, or surgery; OR 3. Difficulty tolerating a prosthesis in an anophthalmic socket; OR 4.
What is a good age for blepharoplasty?
When you reach the age of 30, your eyelids begin to droop. Blepharoplasty is best done at this age, while it can potentially be done at a younger age. Most plastic surgeons, however, advise that the patient be at least 18 years old before undergoing the treatment. You can have surgery if your upper eyelid skin is obstructing your eyesight and you are younger. Such unusual circumstances might arise as a result of a variety of factors, including spontaneous deformity or accidents.
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 cover hooded eyelid surgery?
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.
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.
Does insurance cover drooping eyelids?
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.
What is the difference between blepharoplasty and blepharoptosis?
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.
What is the visual field test for blepharoplasty?
The cost of ptosis surgery and blepharoplasty in the healthcare setting has long been a point of contention. 1 Medical insurers and Primary Health Care Trusts have published a variety of unreasonable standards (PCTs). 2, 3, 4, 5, and 6 are all numbers. The lack of uniformity and clarity in these standards has resulted in a great deal of ambiguity, giving patients anxiety and generating concerns about a postcode lottery. The demand of an individual case evaluation for each procedure by certain PCT has added to the workload of those participating in the decision-making process. For example, one medical insurance requires a full-face shot indicating that the top lid droops over the pupillary opening to a degree consistent with the aberrant visual field in order to verify that ptosis is a functional handicap. Photographs indicating dermatochalasis and a visual field revealing a defect to at least 30° above the visual axis that is significantly improved or repaired when the lid is taped qualify for blepharoplasty. 2 ‘Blepharoplasty will be commissioned for eyelid ptosis and/or excess skin of the top eyelid, which causes clouded vision,’ according to some insurers’ guidelines. 4
The reflected light from the flash used to illuminate the subject must be in the middle area of the patient’s face in order for a photograph to be considered. However, this is difficult to execute without the assistance of an experienced photographer in a controlled environment, which comes at a high expense. Variability in the height of the eyelid over time, chin position, difficulty in fixation, frontalis over activity, and even the patient’s mood and expression can all alter the validity of the results.
While the visual field has been employed to show the existence of ptosis in some ophthalmic units, there is currently no uniform visual field designed for this purpose. In the United Kingdom, most glaucoma clinics utilize either the Goldmann visual field or the Humphrey 24-2 test. While the Goldmann exam is sensitive and thorough, it is also time-consuming, operator-dependent, and less specific, as some patients may predict the next point. The Humphrey 24-2 test only evaluates a small portion of the superior 24° field, which is significantly less than what most individuals use in their daily lives. Patients with ptosis and dermatochalasis frequently complain of a superior visual field deficiency that is not visible with 24-2 testing but affects their visual function and confidence for activities like driving and crossing the road, as well as occupational needs like engineering. Small et al. found that 97 percent of patients with a marginal reflex distance of 2 mm or less had an upper visual field restriction of 30° or less in their study. 7 Our American colleagues employ Goldmann or automated static perimetry, which has a 10 dB threshold (Humphrey analyzer) or a 7 dB threshold (Humphrey analyzer) (Octopus analyzer). 8 Although the latter is more accurate, it takes a long time to learn and has a high percentage of false positives and negatives. Meanwhile, different custom Humphrey field tests that test more points superiorly have drawbacks such as not testing points in inferior fields, which may create bias, and threshold static testing, which is time demanding, as documented in the literature.
As a result, we created a modified visual field test to evaluate ptosis and dermatochalasis. We hope to use this novel diagnostic technique to highlight the functional impairment caused by these diseases, as well as the effectiveness of surgery in improving the superior visual field.
How long do blepharoplasty results last?
The effects can persist anywhere from 5-7 years in most cases. Blepharoplasty of the lower lids is rarely necessary. If your eyelids begin to sag again over time, a brow lift may be more beneficial than further eyelid surgery.