"When does insurance cover blepharoplasty?"and"How do I get insurance to cover my eyelid surgery?"

When Does Insurance Cover Blepharoplasty?

How to Qualify for Medically Necessary Eyelid Surgery

Blepharoplasty, commonly referred to as eyelid surgery, is one of the most popular procedures in both cosmetic and functional oculoplastic surgery. While it’s often associated with aesthetic improvement, many patients pursue blepharoplasty for medical reasons—such as impaired vision due to droopy upper eyelids (dermatochalasis) or eyelid ptosis.

One of the most common questions patients ask is:“How do I get insurance to cover my eyelid surgery?”or“When does insurance cover blepharoplasty?”

The answer is more straightforward than many think, but it comes with strict criteria. In this article, we’ll walk through exactly when blepharoplasty is covered by insurance, what documentation is required, and why a key number called the MRD1 (Margin Reflex Distance 1) is the deciding factor—even more important than visual field testing or reported symptoms.

What Is Blepharoplasty?

Blepharoplasty is a surgical procedure that removes excess eyelid skin, fat, and sometimes muscle to improve both function and appearance. It can be performed on the upper eyelids (most commonly for functional issues) or the lower eyelids (typically cosmetic).

Cosmetic vs. Functional Blepharoplasty

• Cosmetic blepharoplasty is done to improve appearance—removing puffiness, wrinkles, or sagging.

• Functional blepharoplasty is performed to correct visual field obstruction, eyelid drooping, or other medical symptoms that impact daily life.

Insurance only covers functional blepharoplasty, and very specific clinical documentation is required.

How Do I Get Insurance to Cover My Eyelid Surgery?

To qualify for insurance coverage, patients must meet three main criteria. But one of them—the MRD1—is absolutely essential.

1. MRD1 Measurement of 2.0 mm or Less

MRD1 (Margin Reflex Distance 1) is the distance between the center of the pupil (reflex) and the upper eyelid margin in a normal gaze.

This is the most important factor in determining medical necessity.

✅ If MRD1 is ≤ 2.0 mm, insurance may approve surgery if other criteria are met.❌ If MRD1 is > 2.0 mm, insurance will not approve blepharoplasty, no matter how severe your visual field test or symptoms are.

✅ Key takeaway:If your MRD1 is not 2.0 mm or lower, you do not qualify for medically necessary blepharoplasty.

2. Documented Symptoms Affecting Daily Living (ADLs)

Even with an MRD of ≤ 2.0 mm, insurance carriers also require that you experience symptoms that interfere with daily activities, such as:

• Trouble reading or driving

• Eye fatigue or heaviness

• Difficulty keeping the eyelids open

• Frontal headaches from eyebrow elevation (compensatory action)

These symptoms are usually documented in your surgeon’s history and physical or consultation report.

3. Visual Field Testing (Taped vs. Untaped)

A visual field test using a method like Humphrey or Goldmann perimetry is usually required.

• Untaped: The upper eyelid hangs naturally.

• Taped: The upper eyelid is lifted with surgical tape, simulating the post-op result.

Insurance requires documentation that the taped visual field shows significant improvement—typically at least a 30% expansion in the superior field.

⚠️ Important clarification:Even if your visual field improves dramatically, your MRD still must be 2.0 mm or less for the surgery to qualify.

What Is the Process for Getting Insurance Approval for

Blepharoplasty?

Here’s a step-by-step overview if you’re wondering how to get insurance to cover blepharoplasty:

Step 1: Consultation With an Oculoplastic Surgeon

A specialist (preferably board-certified in oculoplastics) will:

• Take detailed photos of your eyelids

• Measure your MRD

• Review your medical history and symptoms

If your MRD is borderline, they may recommend conservative management before re-evaluation.

Step 2: Visual Field Testing

If your MRD is 2.0 mm or less, a visual field test will be scheduled. Most insurance plans require testing both:

• Untaped (natural droop)

• Taped (lid lifted)

The difference shows whether the surgery would provide functional benefit.

Step 3: Insurance Preauthorization

The surgeon’s office submits:

• MRD measurements

• Photographs

• Visual field test results

• Documentation of symptoms

Each insurance company has slightly different rules, but most follow similar criteria outlined by CMS or medical boards.

What if My MRD Is Greater Than 2.0 mm?

If your MRD is greater than 2.0 mm, even if:

• Your visual field is severely impaired,

• Your symptoms are extreme, or

• You have an obvious droop in photos...

Insurance will still deny coverage.

This strict threshold ensures that only patients with significant functional impairment are approved.

In these cases, cosmetic blepharoplasty is your only option, and it would be paid out-of-pocket.

Which Insurance Companies Cover Blepharoplasty?

Most major U.S. carriers follow similar guidelines. These include:

• Medicare

• Cigna

• UnitedHealthcare

• Blue Cross Blue Shield

• Aetna

• Tricare

Each may have slight differences, but all require:

• MRD ≤ 2.0 mm

• Visual field improvement

• Symptom documentation

Some plans may require prior authorization while others allow post-claim review.

Does Medicare Cover Blepharoplasty?

Yes—but only for functional reasons.

Medicare’s local coverage determinations (LCDs) require:

• MRD of 2 mm or less

• Photographic evidence

• Visual field improvement

• Documentation of symptoms interfering with vision

Medicare does not cover cosmetic eyelid surgery.

Can I Combine Cosmetic and Functional Blepharoplasty?

Yes. This is common, especially if you're interested in improving your lower eyelids, under-eye bags, or fine wrinkles.

Here’s how it works:

• Insurance may cover the medically necessary portion (e.g., upper eyelid lift for drooping).

• You can pay out of pocket for the cosmetic enhancements (e.g., fat sculpting, skin tightening, lower lids).

Surgeons like Dr. Chris Thiagarajah in Denver often perform both procedures in a single surgical session—which can save you time, cost, and recovery.

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This article answers the most critical insurance-related questions about upper eyelid surgery coverage, with a strong emphasis on MRD measurements—which is the true cutoff point in most cases.

Final Thoughts

If you're considering eyelid surgery and wondering how to get it covered by insurance, the most important thing to know is this:

Your MRD must be 2.0 mm or less.

Without this measurement, even the best visual field results or most bothersome symptoms won't qualify you for insurance coverage.

That’s why your first step should be a consultation with a board-certified oculoplastic surgeon who understands the detailed medical criteria—and can guide you through the process.

Schedule a Consultation in Denver, Colorado

If you live in Denver or the surrounding area, Dr. Chris Thiagarajah, MD, is a highly experienced oculoplastic surgeon who specializes in both functional and cosmetic blepharoplasty.

With years of experience navigating insurance criteria, documenting MRD measurements, and performing precision eyelid surgery, he can help determine whether your eyelid droop qualifies for insurance coverage—and guide you through every step.

Contact us today to schedule your consultation and find out whether your eyelid surgery could be covered.