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When does insurance cover eyelid lifting surgery?: Update in 2019

Extra eyelid skin blocking eye
Blepharoplasty before surgery

A common question that patients have is “will my insurance cover my eyelid lift surgery?”. The answer is really “that depends”. Insurance covers eyelid lifting surgery such as blepharoplasty or ptosis repair when the vision is being blocked significantly. What does that mean exactly? There are three criteria that have to be met for insurance to cover eyelid surgery.

1. The eyelid skin or drooping eyelid has to be 2 mm from the center of the pupil

2. The patient needs to have visual symptoms

3. Raising the eyelid will improve those visual symptoms

Lets go over each of these to expand on what each criteria mean. Remember all three criteria have to be met, not just one or two of them.

The eyelid skin or drooping eyelid has to be 2 mm from the center of the pupil

When the eyelid skin is drooping or the eyelid itself is drooping, the vision can be blocked. Insurances usually cover eyelid surgery for drooping eyelids when this skin or tissue is within 2mm of the pupil. They will use the photograph of the patient to measure that distance. It doesn’t matter what symptoms a patient has, if it is not within this distance, insurance will not cover this surgery.

I often have patients with terrible symptoms from their drooping eyelid or skin. They feel things are dark, have trouble seeing peripherally or even question whether they should drive. The unfortunate truth is that unless that skin or eyelid is within the 2mm of the pupil, the insurance is not going to pay for it regardless of the symptoms. It doesn’t matter if it will eventually get there or if it is close.

The patient needs to have visual symptoms

In order for a patient to have insurance coverage for blepharoplasty or eyelid lifting, the patient needs to have visual symptoms. Examples of this include:

“I have trouble seeing”

“I bump my head against things”

“I can’t drive”

“It interferes with reading”

“ I have to raise my eyelid to see”

Insurance companies do not care about cosmetic symptoms such as:

“My friends say I look sleepy”

“I don’t like how I look”

“I feel I look tired”

How one feels or looks is important but unfortunately insurance will not cover those eyelid surgeries for appearance. Those are what we call “cosmetic symptoms”.

Raising the eyelid will improve those visual symptoms

Sometimes I have patients who come in with a drooping eyelid who have an eye that is not seeing. This can be a prosthetic eye or even an eye that has disease from glaucoma or macular degeneration. If raising the eyelid will not improve the vision, insurance will not cover the surgery. This would be considered a cosmetic and not functional improvement.

These are the three criteria for eyelid lifting coverage in my practice in Denver which are critical to know.

Other basic things important to know about insurance coverage for eyelid surgery.

- Insurance never covers cosmetic blepharoplasty of the lower eyelid (eye bags)

- If you are having a medical eyelid procedure (blepharoplasty of the upper eyelids) you can choose to have the lower eyelids done at the same time

- The authorization process takes two weeks on average

- Some insurance companies (like Cigna) do not cover blepharoplasty or eyelid surgery under any circumstance even if all three criteria are met

Hopefully this helps patients understand eyelid surgery and coverage. If you are interested in eyelid surgery like blepharoplasty I advise you to come to our office for a consultation. 303 468 8844

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