December Case of the Month: The Drooping Eyelid and Insurance
A 55 year old patient presented with drooping of both that blocked her vision when driving and reading books. She was found to have ptosis of both upper eyelids. During preoperative counseling ptosis versus dermatochalasis along with blepharoplasty and ptosis repair were discussed. She underwent successful ptosis surgery and returned questioning whether "enough skin was removed during the surgery". The patient felt her vision was better but she wasn't happy with how her eyelids looked. Specifically, the skin on upper eyelids were still present. She confirmed that her neighbor "had an eyelid lift" and now all the loose skin were gone.
It was was rediscussed with her the expectations of ptosis repair versus the cosmetic improvement seen with a cosmetic blepharoplasty. The patient then considered cosmetic improvement of her eyelids in the future though certainly was disappointed that it was not provided as a free service by the surgeon.
I thought I would discuss the most common questions surrounding both procedures that referral doctors ask myself and my partner Dr Jerry Popham. Though ptosis repair and insurance blepharoplasty are functional procedures that are done to improve vision, many patients have a "cosmetic surgery" approach to these patients. It is important for the surgeon to properly educate the patient on what is and is not covered by insurance as patients often have misconceptions. Additionally the subtle differences between ptosis repair and blepharoplasty are lost among patients who view these procedures under the lump term of "eyelift".
When does insurance cover ptosis repair?
For insurance companies like Medicare or Blue Cross to cover ptosis repair there are three requirements that all must be met:
1. The patient has a visual functional limitation from their drooping eyelids
2. The eyelids must be within 2 mm from the pupil
3. The functional limitations must affect activities of daily living
For clarification, the limitation of vision that patients complain of are usually tested by visual field testing with the eyelids in a drooping position and also taped up. This is done commonly with a Tangent field or Goldmann Field testing. Additionally, limitations of daily living can include driving, reading, watching TV. Patients can also complain of bumping into things. Symptoms that insurance companies will not cover include:
" I don't like the way my eyelids look"
" Everyone thinks I look sleepy"
" I can't put makeup on"
Often I tell patients that insurance companies care about how you see not how you look. If appearance is the main concern, then ptosis repair would be considered a cosmetic procedure.
What about blepharoplasty? When does insurance cover this procedure?
The short of it is that insurance companies cover blepharoplasty for loose skin under the same guidelines. In some cases if the loose skin is resting on the lashes and causing irritation that can be seen in blepharochalasis syndrome, it also can be covered.
If a patient gets a ptosis repair, is a blepharoplasty done at the same time?
The short answer is "sort of". Ptosis repair and blepharoplasty are bundled procedures. That means that if a patient needs both procedures to see well, they are covered. (In fact oculoplastic surgeons get paid for only one procedure). That is an important distinction because a cosmetic blepharoplasty is not covered by insurance. So certain ptosis procedures such as Muellers Muscle Conjunctival resection and Small Stitch Ptosis repair do not have skin removal as part of the procedure. Often patients hope and want that they will get a cosmetic blepharoplasty at the same time as their ptosis procedure. The reality is that skin removal (or fat removal) is not a standard part of ptosis repair. The only exception is when the excess skin is expected to cause a visual symptom and be within 2 mm of the pupil. Additionally confusing for patients is that they believe that excess skin causes ptosis and are not aware of levator muscle weakness or the underlying techniques to repair them.
This case illustrates a patient with ptosis where blepharoplasty would be covered. Certainly the eyelid skin would block the vision if the eyelids were raised alone
This case illustrates a case where blepharoplasty would certainly not be covered by ptosis repair as it does not cause a functional limitation. As can be seen in the "after" photo, it does not.
Can patients elect to have cosmetic blepharoplasty with ptosis repair if it is not covered?
In short, yes. For 2017 Medicare made it illegal to combine both procedures initially but then reverse their decision recently.
What about puffiness of the upper eyelids? Is that covered under ptosis repair?
Like extra skin, fat removal is covered if it is expected to cause a visual problem after ptosis repair.
Some surgeons perform blepharoplasty on all ptosis patients. Is that kosher?
It can be a gray line of how much skin excision is kosher or within insurance guidelines. It is certainly reasonable to remove some skin that can bunch up during a ptosis repair. That being said, providing a cosmetic blepharoplasty at the same time as ptosis repair is most likely a violation of the insurance contract. Though the surgeon is not charging for their extra work, the insurance company is certainly paying for extra OR time and anesthesia time. Whether this would go under "insurance fraud" could be debateable but certainly could result in a surgeon being thrown off an insurance panel.
Hopefully this clears up some confusion about ptosis and blepharoplasty. Many patients have confusion about what is actually covered in the procedure. A good preoperative counseling can help these patients, however sometimes patients can still be dissatisfied with the cosmetic outcome of ptosis procedures that are related to excess skin. Hopefully this article helps eye doctors answer any questions as they apply in 2018 for patients with drooping eyelids.
Have a topic that is of interest to you? Let me know and I can present a case with a review next month. My email is email@example.com.