How Does Medicare Approve Blepharoplasty? A Complete Guide for 2026

By Chris Thiagarajah, MD – Oculoplastic Surgeon, Denver Eyelid Specialists

Board-Certified Ophthalmologist • Fellowship-Trained Oculoplastic Surgeon

Over 15,000 eyelid procedures performed

Introduction

Many Medicare patients struggle with heavy eyelids that block their vision while reading, driving, or performing daily tasks. But because eyelid surgery can be either functional or cosmetic, Medicare now requires a formal preauthorization process before approving blepharoplasty.

This guide explains the exact criteria, tests, documentation, and timeline Medicare uses to approve or deny eyelid surgery in 2026—along with easy-to-understand charts.

What Is Blepharoplasty—and When Will Medicare Pay for It?

There are two categories of eyelid surgery:

✔ Functional Blepharoplasty (Covered if criteria are met)

Medicare pays if your eyelids physically block vision.

✔ Cosmetic Blepharoplasty (Not covered)

Performed to reduce puffiness, remove eyelid bags, or improve appearance.

Medicare pays only if medical necessity is proven.

⭐ Medicare’s New Rule: Prior Authorization Is Required

As of 2024–2025, Medicare requires prior authorization for:

• Functional upper blepharoplasty

• Ptosis repair

• Brow ptosis repair

Your surgeon must send Medicare proof that your eyelids block vision before surgery can be scheduled.

Medicare’s Criteria for Approving Blepharoplasty

To be approved, patients must meet all three categories:

1. Documented Symptoms Interfering With Vision

Symptoms must affect daily life, such as:

• Needing to lift eyelids manually

• Trouble reading

• Difficulty seeing signs while driving

• Reduced peripheral vision

• Eye fatigue or headaches

• 
  

These must be written in your chart, not just mentioned verbally.

2. Physical Exam Findings

The key measurement Medicare looks for is MRD1 (how far the eyelid margin sits above the pupil light reflex).

Medicare typically requires:

✔ MRD1 ≤ 2.0 mm(Some regions require ≤ 1.5 mm.)

Doctors must also document:

• Brow position

• Dermatochalasis severity

• Compensatory brow lifting

• Interference with eyelashes or visual axis

• 
  

3. Visual Field Testing

Medicare requires formal visual fields with and without the eyelid taped.

Approval requires one of the following:

✔ 12° or 24% loss of the upper visual field

OR

✔ 30% improvement when taped

This proves vision improves when the eyelid is raised.

📊 Chart: How Medicare Approves Blepharoplasty

Here is an illustrative breakdown (not actual Medicare data, but patient-friendly visualization):

This chart shows why most patients need proper photos, visual fields, and MRD1 measurements to qualify.

What Your Surgeon Must Submit for Preauthorization

Your doctor sends Medicare:

✔ Standardized Eyelid Photos

• Straight gaze

• Brow relaxed

• High-resolution lighting

• Demonstrating skin overhang or ptosis

✔ Visual Field Test Results

With taped and untaped comparison.

✔ Detailed Exam Documentation

Including MRD1, brow ptosis, skin redundancy, and eyelash interference.

✔ Description of Symptoms

Documented impact on daily vision.

✔ A Statement of Medical Necessity

Explaining how surgery restores function.

What Happens After Medicare Submission?

1. Your doctor submits the packet.

Typical review time: 7–21 days

2. Medicare responds with one of three outcomes:

✔ Approved

You may schedule surgery immediately.Approval significantly reduces future billing risk.

✔ Request for More Information

This may happen if:

• Photos are unclear

• Visual field test quality is poor

• Brow position is not documented

❌ Denied

You may still:

• Appeal

• Repeat testing

• Proceed as cosmetic if you choose

• 
  

Why Medicare Denies Eyelid Surgery

Common denial reasons include:

❌ MRD1 measurement above threshold

❌ Insufficient symptom documentation

❌ Cosmetic motivation mixed with functional symptoms

How the New Rule Affects Medicare Patients

✔ More certainty

Once approved, Medicare is unlikely to deny payment later.

✔ Longer wait before surgery

Because preauthorization takes time.

✔ More testing

Repeat visual fields or photos may be required.

✔ Clearer distinction between medical necessity and cosmetics

Your surgeon will explain which category you fall into.

Does Medicare Cover Lower Eyelid Blepharoplasty?

❌ No — almost never.

Lower eyelid surgery is cosmetic unless:

• Eyelid turns inward (entropion)

• Eyelid turns outward (ectropion)

• There is exposure keratopathy

• 
  

Lower eye bags or puffiness are not covered.

How to Improve Your Chances of Getting Approved

✔ Be specific about how your lids interfere with vision

(Don’t just say “my eyelids feel heavy.”)

✔ Avoid raising your eyebrows in photos

This hides brow ptosis and can cause denial.

✔ Choose a surgeon experienced in Medicare documentation

Oculoplastic specialists have the highest approval rates.

Frequently Asked Questions

How long does Medicare approval take?

Usually 1–3 weeks.

Do I still have to pay anything?

Yes—standard deductibles and 20% coinsurance unless you have supplemental insurance.

Can Medicare approve a brow lift?

Yes, but only if your low brow is part of the visual obstruction and often the technique approved is not cosmetically optimal

Can I combine functional and cosmetic surgery?

Yes. The functional part is covered; cosmetic portions are an add-on fee.

Conclusion

Medicare’s new rules for blepharoplasty aim to ensure that only truly vision-impairing cases receive coverage. With proper documentation—photos, MRD1 measurement, visual field testing, and symptom history—most patients with genuine obstruction are approved.

If you're a Medicare patient wondering whether you qualify, consult with an oculoplastic surgeon who understands the new 2025 preauthorization process and can guide you through each step.