In today’s post, I’ll cover a common question, “Will insurance pay for my eyelid lift surgery?” I hear this question often, because as an oculofacial plastic surgeon, I specialize in cosmetic and reconstructive surgery of the eyelids and surrounding areas of the face. I hope that by reading this post, you’ll have a better idea of what information is required to answer this question.
Let’s start by looking at this question from the perspective of the insurance company. The insurance company’s goal is to confirm that your eyelids or eyebrows need surgery, or in their language, that eyelid lifting surgery is a “medical necessity.” Although each company is different, most companies approach the question of “medical necessity” in a similar way, relying on a combination of your symptoms, my exam and in-office testing. Let’s begin by focusing on how your symptoms impact whether your eyelid lifting surgery is a “medical necessity.”
Generally, the insurance company will want to know that your lids prevent you from doing the things you like and need to do. Ask yourself, “Do my eyelids prevent me from enjoying my hobbies?” “Do my eyelids interfere with my ability to working or drive?” If you answered yes to either of those questions, it suggests that your problem may be covered by insurance. But it’s not enough for your eyelids to interfere with your activities. Insurance companies also want to know what I, as your surgeon, find on my examination.
When I examine a patient that is bothered by drooping eyelids or eyebrows, I usually have a different set of goals than your insurance company. I examine my patients with drooping eyelids to clarify what is causing the drooping and how to best correct the problem. To do this, I make a number of measurements and evaluations. At the same time, the insurance company wants to know what I saw on my examination so that they can answer another question: “Do your symptoms fit my exam?”
Insurance companies also like to see photographs of your eyelids and eyebrows, again to confirm that everything fits together. Most companies look for similar things on the photographs, with some differences. Commonly, they look to see where the eyelids sit compared to the center of the eye, or whether the eyelid skin rests on the eyelashes. These are just some general guides, so keep in mind that your insurance company may have their own approach.
Often, the final piece of the puzzle from the insurance company’s perspective is a side vision test, also known as a visual field. Many patients that come to our office have had a side vision test in the past, but generally, those tests were being used for a different reason. Perhaps the most common reason patients get a side-vision test is to check for an eye condition known as glaucoma. For patients with drooping eyelids, the approach to side-vision testing is quite different. In the case of drooping eyelids, insurance companies want to know if lifting the eyelids with an eyelid lift surgery will make a difference. The way to answer this question is to have patients take the side vision test with their eyelids relaxed, and then repeat the test with the eyelids taped up and out of the way. Insurance companies view taping the lids up as a simulation of what eyelid lifting surgery might accomplish. As you can imagine, this isn’t a perfect test or simulation, but it is commonly required by insurance companies to show that eyelid lifting surgery is a “medical necessity.” Not all insurance companies require this test, so you may not need it.
After we gather all of this information, we will summarize the results and submit them to your insurance company for prior authorization; keep in mind, not all insurance companies will tell us beforehand if eyelid lifting surgery is a “medical necessity.” It often takes several weeks for an insurance company to reach a decision.
If your insurance company feels that your surgery is not a “medical necessity,” you still have options. One option is to simply wait and repeat the testing at some point in the future. Since most eyelid surgery is elective, it is frequently reasonable to wait until you meet your insurance company’s criteria. Another option is to proceed with the surgery “cosmetically.” The only difference in choosing this route is that your insurance company will not pay for the surgery, but from a surgical perspective, I take the same great care of patients that have an eyelid lift, regardless of whether the patient or the insurance company pays for the surgery.
In summary, it’s difficult for us to know whether your insurance company will cover an eyelid lifting surgery before evaluating you. I am happy to evaluate you in person and hopefully help you get a clear answer as to whether an eyelid lifting surgery would be covered in your case. Even if the surgery is not covered, you still have options to get the care you need. Please give us a call to schedule a personalized consultation at 563.213.5080.