Eyelid Surgery is performed in two types, Functional Surgery or Cosmetic Surgery. In this article, we explain when insurance is applicable to this treatment? How to get insurance? with evidence.
Types of Eyelid Surgery
Medical Causes (Functional Blepharoplasty)
- Ptosis: Drooping eyelids (Ptosis): Excessive drooping of the eyelids over the eyes, obscuring and cutting off vision. Surgery is performed to correct this.
- Dermatochalasis: Excessive skin growth on the upper eyelid can obscure vision. Surgery can be performed to correct this problem.
- Lagophthalmos: Inability to close the eye completely. This can cause dryness or loss of protection in the eyes. Surgery can also be performed for this.
Cosmetic Blepharoplasty
- A treatment that is performed to make the eyes look younger without the appearance of tired lines.
- A treatment that is performed to make the eyes look bigger, more vibrant, and more beautiful.
When is Eyelid Surgery Covered?
Insurance companies do not cover cosmetic surgery. But insurance is available only if there is a medical need. Conditions for this…
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1.Vision Impairment
This insurance is available when the skin or muscle of the eyelids is excessively drooping and obscures about 50% or more of the vision. But this must be confirmed through a Visual Field Test.
What does it mean?
This surgery is considered a medical necessity only if the eyelids are a major obstacle to vision. Insurance is available only if it is a medical necessity.
2.Interference with Daily Activities
If you have difficulty in daily activities such as driving a car, reading a book, working on a computer, or if you have symptoms such as headaches or eyestrain, this is considered a medical problem.
What does it mean?
Only if your activities are affected by drooping eye skin can you be assessed as a medical necessity and included in the insurance.
3.Medical Documents
- An ophthalmologist must provide a medical report stating that this surgery is necessary.
- You must take and post before/after photos of how your eyes obscure your vision.
What does this mean?
You will not be able to get insurance without a medical report from an ophthalmologist and photographic evidence.
How to get Insurance?
1.Check Your Insurance Plan
First, you need to contact your insurance company and make sure that your insurance plan covers “Functional Blepharoplasty”, a medically necessary eyelid surgery.
What does it mean?
Not all insurance plans cover this surgery. So, you need to ask directly if your plan covers it.
2.Collect Medical Evidence
Visual Field Test
This is called a visual field test. This test will determine if the eyelid or skin is covering 30% or more of your vision. This information is an important piece of evidence for your insurance claim.
Ophthalmologist’s Medical Report
An ophthalmologist’s report is required to certify that you have conditions such as ptosis (drooping eyelid) or dermatochalasis (skin thickening). The report should state that this surgery is necessary.
What does it mean?
Insurance coverage is available only if you have a visual field test and a written recommendation from a doctor.
Excluded Procedures
Not all eye-related procedures are covered. Insurance companies, in particular, deny some cosmetic procedures. These procedures include…
1.Brow Lift
A cosmetic procedure that lifts the eyebrows to give a younger look to the face. It is not medically necessary! And it does not cause any visual impairment. Since it is a cosmetic procedure, insurance coverage is not available.
2.Fat Removal
A procedure to remove excess fat around the eyes. This is done to improve beauty. This procedure does not cause any visual impairment or health problems. Therefore, it is not covered by insurance.
3.Double Eyelid Surgery
This is a cosmetic surgery. It is performed to create double-folded eyelids (commonly popular in Asian countries). This is not covered by insurance because it is a procedure that does not cause vision problems or is medically necessary.
Examples of Medical Conditions
Ptosis (drooping eyelid)
- A condition in which the eyelids droop and obscure vision.
- This surgery is covered by insurance.
- This is a medical condition that directly affects vision. Therefore, it is covered by insurance.
Dermatochalasis
- This is a condition where the skin on the eyelids increases and obscures vision.
- This surgery is covered by insurance.
- It can cause vision loss. Therefore, it is covered by insurance because it is medically necessary.
Lagophthalmos (inability to close the eye completely)
- Difficulty closing the eye. This can lead to dry eyes and other problems.
- This is covered by insurance.
- This is a medical treatment that is necessary for eye health. Therefore, it is covered by insurance.
Blepharochalasis (eyelid swelling and drooping)
- There is constant swelling of the eyelid. This causes sagging skin. This can lead to vision loss.
- This is covered by insurance.
- This is a medical condition that can cause vision loss and therefore is covered by insurance.
Malar Festoons
- Sagging skin under the eyes is a problem. But it does not directly affect vision.
- This is not covered by insurance.
- This is considered a cosmetic problem. Insurance is not available because there is no vision impairment or medical necessity.
Insurance Plans and Coverage
Medicare
Medicare covers eyelid surgery. Functional Blepharoplasty is covered under Procedure Codes 15822/15823. Ptosis Repair is also covered under Medicare under Code 67904.
Medicaid
Medicaid is a state-by-state program. Therefore, the rules vary from state to state. Prior Authorization is required to obtain Medicaid coverage for this procedure.
Private Insurance
Popular private insurance companies such as United Healthcare, Aetna, and Blue Cross will provide coverage for Functional Blepharoplasty or Ptosis Repair if there is a 50%+ vision impairment documented by medical documentation.
How to Choose a Doctor?
- Choose a surgeon who is certified by the American Society of Ophthalmic Plastic Surgeons (ASOPRS).
- ASOPRS certification is a reliable sign that the surgeon has specialized training in ophthalmic plastic surgery.
- Make sure that the surgeon has at least 5 years of experience in this field.
- Patients can read reviews on sites like Google to find out about the surgeon’s handling, clarity of explanations, and success rate.
Important Questions and Answers
How much does Eyelid Surgery Cost?
The cost of this procedure can range from $500 to $2,000. This cost may not be fully covered by your insurance plan and will be at your own expense, especially for those without insurance. The cost will vary depending on the individual hospital, the surgeon’s experience, and the city where the procedure is performed.
Will Insurance cover the Entire Cost?
No, even if you have insurance, the entire cost will not be covered by the insurance company. Generally, you will have to pay the deductible (i.e. the amount you already pay) and the co-pay (your share of the cost). This is why even with insurance, you will still have a small out-of-pocket expense.
What to do if the Insurance Company Denies Your Application?
Don’t accept the denial right away. You can appeal.
For that, you need to collect and submit evidence again, such as a new medical report from your ophthalmologist and a Visual Field Test.
Conclusion
Documents proving medical necessity are required to get Eyelid Surgery insurance. Claim with the Visual Field Test and the doctor’s report. Remember that insurance does not cover cosmetic treatments!