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Eyelid Lifts: Does my insurance cover this procedure?

An upper eyelid lift, or blepharoplasty, is one of the most common surgical procedures that Dr. Lee performs as an oculofacial plastic surgeon. During consultations, a frequent question from patients is whether their eyelid lift will be covered by insurance. Depending on how droopy the eyelids are, an insurance company may cover a blepharoplasty.

While insurance criteria can vary from one insurance provider to another, typically there are a number of criteria that most insurance companies require to be met.

Does your eyelid droopiness affect your daily life?

These criteria are used in order to try to determine if the droopy eyelids are interfering with one's vision. Therefore, the insurance companies will typically require that patients are symptomatic from their eyelids. For instance, if a patient comes in stating that she is having a more difficult time driving because she cannot see the cars next to her due to her droopy eyelids, this would qualify as a symptom that shows how much the eyelids are impacting her daily life.

Photographs and clinical notes are used to determine eligibility for insurance based eyelid lift.

In addition, insurance companies will ask for clinical notes and photographs taken during the clinical exam. During an examination, I check how droopy an eyelid is and will notate it with a measure called the MRD, or the margin reflex distance. This is the distance between the light reflex I can see on a patient’s eye when shining a light directly onto it and the edge, or margin, of the eyelid. This distance is normally 3-5 mm. If it is 2mm or less, your insurance company may cover the procedure.

What is peripheral visual field testing?

Finally, most insurance companies will require a peripheral visual field test. In this test, a patient's peripheral vision is evaluated. First, we check how well a patient sees in her periphery. Next, we will raise or tape the eyelids up and recheck the peripheral vision. If the peripheral vision significantly improves when the eyelids are raised or taped, this proves that the droopy eyelids are interfering with the patient’s vision.

After all of this information is collected, it is sent to the insurance company in order to get pre-authorization, or pre-approval, for the surgery, though Medicare does not require this step. Typically, pre-authorization is obtained within a couple of weeks; however, occasionally, this process may take longer. Once pre-authorization for the surgery is approved, then we can proceed with surgery. Though Medicare does not require prior authorization, we go through these steps of evaluation in case Medicare asks for proof of necessity.

If you are bothered by your droopy eyelids, please contact the Lee Aesthetic Center at 908-738-1160. Dr. Henry Lee, a fellowship trained oculofacial plastic surgeon, has extensive experience with eyelid lift (blepharoplasty) surgery and will inform you regarding whether or not your insurance will likely cover your procedure.


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