One of the most frequently asked questions by my patients is, “does insurance cover blepharoplasty?” Or “will my insurance cover eyelid surgery?”.
This is a great question. Most insurance companies have specific guidelines and criteria regarding coverage for eyelid surgery. I will try to focus on this article to cover the required criteria for repairing ptosis and/or blepharoplasty. While there may be subtle differences between different carriers, Medicare guidelines and off-base insurance companies’ criteria for Medicare may vary.
If the upper lids obstruct a significant portion of your vision, impacting your daily activities, insurance companies will typically provide coverage for blepharoplasty or ptosis repair. In other words, if the obstruction caused by the eyelids affects your daily life in a visually significant manner, insurance may consider these procedures medically necessary and cover their costs.
What are the 3 pieces of information that insurance companies require in order to determine if blepharoplasty or upper eyelid surgery is considered “visually significant” and eligible for coverage?
The eyelid or surplus skin comes within a distance of less than 2 millimeters from the pupil (also known as an MDR1 less than 2mm), indicating that the position of the eyelid should be evaluated using standard oculoplastic measurement methods. Patients often complain about the upper lids hindering certain activities such as driving and reading, which result in a reduced visual field. The position of the lids must be clearly recorded in the physician’s notes.
High-quality frontal and side photographs are necessary. The eyelids or any excess skin around the eyelids should be clearly visible, falling within a distance of less than 2 millimeters from the center of the pupil to meet the criteria. Essentially, these are detailed images of the eyelids and eyes. Additionally, external ophthalmic photography is also required.
The improvement of the visual field must meet a specific percentage or number of degrees, depending on the insurance provider. Insurance coverage for upper eyelid surgery is determined by the discrepancy between the taped and untapped visual field. The ophthalmology office typically conducts a visual field test by examining the field of vision with the eyelids in their natural state and then held up using tape. This noninvasive test is used to assess peripheral vision. 3) Evaluation of Peripheral Vision.
Occasionally, there are a few indications that insurance companies will accept to cover upper eyelid reconstruction surgery, such as chronic dermatitis and congenital ptosis (drooping of the eyelid) in children born with thyroid eye disease.
Once an oculoplastic surgeon evaluates whether or not they feel upper eyelid surgery is medically necessary, they will determine and evaluate it.
If the patient’s claim is denied, they can appeal and consider submitting a pre-authorization for cosmetic surgery. The insurance carrier may occasionally deny the original pre-authorization but will review the case again after the surgery has been performed. Insurance carriers do not guarantee 100% coverage, but it is reassuring that they agree that eyelid surgery for repair of ptosis or blepharoplasty is medically necessary. The insurance company will either deny or “pre-authorize” the claim, and the next step is to submit all testing and notes to the insurance company. If they approve, the answer is yes.
Medicare works a bit differently when it comes to eyelid surgery or blepharoplasty coverage. Most oculoplastic surgeons will give a fairly accurate assessment to determine whether Medicare will cover the procedure. However, if the claim is denied, the patient is typically responsible for the payment, as stated in the ABN form, which is usually signed and completed by the patient. While most oculoplastic surgeons are correct in their assessment of Medicare coverage, Medicare does not pre-authorize the surgery. If the testing and examination provide enough detail, Medicare may determine that eyelid surgery is typically covered for the patient. However, it is important to note that Medicare has clearly defined criteria that most oculoplastic surgeons are knowledgeable about.
Hopefully, this provides some insight about the criteria and process for repairing ptosis or blepharoplasty and obtaining insurance coverage. If you have any questions, please contact us at 8717-999-949.