One of the most common questions my patients ask is, “does insurance cover blepharoplasty?” or “Will my insurance cover eyelid surgery?”
This is a great question. Most insurance companies have specific guidelines regarding the criteria for covering eyelid surgery. I will try to focus this article on the insurance criteria necessary to cover blepharoplasty and/or ptosis repair. While there may be subtle differences between different companies, most insurance companies base their criteria on Medicare guidelines.
In general, insurance companies will cover blepharoplasty or ptosis repair if the eyelids cause a “visually significant” upper visual field obstruction that “impairs activities of daily living.” To put it another way, if your upper eyelids block your vision enough to significantly affect your life, then blepharoplasty or ptosis repair is considered medically necessary and may be covered by insurance.
So, what are the criteria insurance companies use to determine if blepharoplasty or upper eyelid surgery is “visually significant” and therefore covered? there are 3 pieces of information they need:
1) doctor’s notes. these notes should clearly document lid position, decreased visual field, and a patient complaint of upper lids interfering with certain activities (driving, reading, etc.). Lid position should be measured using standard oculoplastic measurement techniques showing that the lid or excess skin is less than 2 millimeters from the pupil (also called mdr1 less than 2 mm).
2) external ophthalmic photography. basically these are high resolution photos of the eyelids and eyes. for the criteria to be met, the eyelids or additional eyelid skin must be clearly seen to be within 2 millimeters of the center of the pupil. clear front and side photos are required.
3) visual fields. A visual field test is a noninvasive way to assess peripheral vision. This test is usually done in an ophthalmology office. the field of vision is tested both with the eyelids in their natural position and with the eyelids raised (usually with tape). the difference between the recorded and unrecorded visual field determines whether or not insurance will cover upper eyelid surgery. the visual field should improve by a certain percentage or a certain number of degrees depending on the insurance company.
Occasionally, there are other indications that insurance companies will accept to cover upper eyelid surgery. reconstruction after thyroid eye disease, children born with ptosis (congenital ptosis), and chronic dermatitis due to eyelash rubbing are some of these indications.
Once an oculoplastic surgeon has all the necessary information, they will evaluate it and determine whether or not they believe upper eyelid surgery is medically necessary.
If the answer is yes, the next step is to send all the notes and evidence to the insurance company. the carrier will then “preauthorize” or deny the claim. A prior authorization means that the insurance company agrees that the eyelid surgery is medically necessary and plans to cover the blepharoplasty or ptosis repair. Although a prior authorization is very reassuring, it is not a guarantee of 100% coverage. occasionally insurance companies will do a second review of the case after the surgery has been performed. it is unusual, but occasionally the insurer may deny the original pre-authorization and consider cosmetic surgery. an appeal can be filed if this occurs, however, if the claim is denied again, payment is generally the responsibility of the patient.
Medicare works a little differently. Medicare doesn’t pre-authorize anything (any procedure, not just eyelid surgery). however, medicare has clearly defined criteria that are fully understood by most oculoplastic surgeons. Based on the exam and tests, it can be determined if Medicare would normally cover a patient’s eyelid surgery. While most oculoplastic surgeons are correct in their assessment of coverage, since Medicare will not preauthorize the surgery, the patient typically completes and signs a form called an “ABN.” The ABN generally states that while the surgeon believes Medicare will cover the blepharoplasty or ptosis repair, the patient is responsible for payment if the claim is denied. Again, most oculoplastic surgeons will be able to provide a fairly accurate assessment of whether Medicare or an insurance company will cover blepharoplasty or eyelid surgery.
Hopefully this provides you with information about the process and criteria for insurance coverage for blepharoplasty or ptosis repair. please contact us at (949) 999-8717, or contact us if you have any questions.