Cosmetic vs. Functional Eyelid Lift (Blepharoplasty): Will insurance pay?
As an oculofacial plastic surgeon, I am referred many patients for drooping eyelids. Excess skin of the eyelid is termed dermatochalasis. Often, the drooping eyelids interfere with the patient's vision. Sometimes, the patient's chief complaint is that the eyelids feel heavy and that they are straining to keep the eyelids open. Upper eyelid blepharoplasty, or an upper eyelid lift, is a procedure that removes some of the excess upper lid skin. It often improves the patient's ability to see. It also makes the patient look younger and more refreshed. So does insurance cover upper eyelid blepharoplasty? The answer is sometimes. Let me explain the rules. Insurance will often consider a blepharoplasty as a medically necessary procedure. This means that the surgery will be covered by the insurance policy. However, certain criterion must be met and documented by the physician. First, the patient must have visual complaints pertaining to the drooping lids. For instance, a patient may state that they can't read well because their eyelids are too heavy and are closing. Another patient may state that they have been in a fender bender because they have impaired peripheral vision due to the droopy lids. At times the droopy lids are secondary to an underlying illness such as muscular dystrophy or myasthenia gravis. I have been referred people whose lids are so droopy that they either tape their eyelids open or manually elevate their eyelids with a finger in order to see. These are legitimate complaints and the suffering patient deserves and is entitled to have their blepharoplasty covered by insurance. But the plot thickens. A complaint is not enough to have your blepharoplasty covered by insurance. Most insurance carriers require documentation that the drooping lids are restricting the patient's peripheral visual field. This is documented by having the patient take a visual field test. This is a test where examinee looks into a semicircular dome, one eye at a time, and presses a button when they see a flashing light. This test is performed twice. Once, with the eyelid in its native or drooping position and once with the lid manually elevated. If the test documents that the peripheral visual field is significantly restricted, or that there is significant improvement in the visual field with the lid manually elevated compared to the native position, then the insurance carrier will often deem the lid droop as a "functional" impairment and cover the procedure. In addition to a visual field test, some insurance companies require that the physician record and submit certain eyelid measurements. Most require photographs of the patient's eyelids, in various positions, to help determine if the drooping lids are interfering with the peripheral visual field. Also, most insurance carriers require "prior approval" for the surgery. Simply put, this means that the insurance company will review all the submitted and relevant information prior to determining if the procedure will considered medically necessary and subsequently paid for. This may sound like a lot of hoops to jump through for a relatively minor procedure. In the insurance companies defense, many people want blepharoplasty not to improve their vision, but to improve their appearance. Cosmetic surgery is not routinely covered by insurance and there needs to be an objective way to decipher who will medically benefit from the procedure. I suggest that if you are considering an upper lid blepharoplasty, that you consult an experienced oculofacial plastic surgeon who will be able to explain the risks and benefits of the procedure and answer all your questions regarding coverage. Steven Covici, MD, FACS