Many people experience eyelids that are heavy and drooping. This is common due to natural aging and poor lifestyle habits. Skin sagging and heavy upper eyelids make it difficult to see. It can also impact your appearance and make you look much older than you are. Heavy upper eyelids can also make you look tired and angry, even if you are happy and have had a good night’s sleep. This can impact your self-confidence tremendously. If you struggle with reading, driving, or just keeping your eyes open without fatigue, upper eyelid surgery is right for you. Many people get the surgery for cosmetic reasons. However, it also addresses functional issues caused by sagging upper eyelids. You may wonder, will my insurance cover the cost of eyelid surgery? Below you will find more information about coverage options and why the procedure is right for you.
Will My Insurance Cover the Cost of Eyelid Surgery?
There is a distinction between cosmetic and medically necessary procedures. The vast majority of insurance companies do not cover cosmetic surgeries. However, upper eyelid surgery can be categorized as cosmetic or medically necessary. Surgery may be covered when it is medically necessary for functional reasons. Check with your insurer and consult with an oculoplastic surgeon for more information.
When Will Insurance Cover Eyelid Surgery?
Insurance may cover upper eyelid surgery if you meet certain criteria. When the skin sagging on the upper eyelid is so severe that it impacts your daily life, it may be covered. Surgery is no longer considered cosmetic when there are functional issues caused by skin sagging. Each insurance company has its own criteria. Check directly with your insurer to determine the criteria necessary for medical necessity. Insurers require proof of visual impairment before covering the cost of surgery. Below are some of the common factors that indicate insurance may cover the cost of the surgery.
Difficulty with Daily Tasks
If upper eyelid sagging impacts your daily tasks, insurance may cover it. Common examples include trouble reading, driving, or working due to sagging lids. When the issue impacts your daily life, the surgery is no longer considered cosmetic.
Eye Strain
If you strain your forehead muscles to keep your eyes open, that is a functional issue. Some people also experience eye fatigue due to raising their eyebrows to see. You may notice eye strain when working on a computer, driving, or reading.
Visual Obstruction
Surgery may be medically necessary if your upper eyelid droops so low that it blocks your vision. This is especially common in the upper and outer corners of the eye.
Documents Necessary to Prove Medical Necessity
To determine whether your eyelid surgery is medically necessary, you need to gather documentation. This is necessary to prove to your insurer that you meet their specific guidelines. Work with your oculoplastic surgeon to gather the information demonstrating why you need eyelid surgery for functional reasons.
Physical Exam by an Oculoplastic Surgeon
If you want to move forward with upper eyelid surgery, schedule a consultation with an oculoplastic surgeon. They will perform several exams and tests. These are performed to determine the severity of obstruction caused by your upper eyelids. They will perform a physical examination of your eyelids. They will assess your symptoms to determine whether you meet the criteria.
Visual Field Test
The oculoplastic surgeon will also perform visual field tests. A peripheral vision test is necessary to assess your side vision. This is done using a special machine and may be done twice. The first time it will be performed when your eyelids are in their natural position. The second test is often done with your eyelids lifted with tape. If the results show a clear improvement with the lid lifted, it supports the need for surgery due to functional issues.
Photos
Insurance companies often require photos to demonstrate the excess skin. Photos taken straight on and from the side are necessary. The oculoplastic surgeon will take photos of your eyelids at rest and with facial movements. With the photos, your oculoplastic surgeon will include written documentation of your symptoms. Any explanation of why surgery is medically necessary is also included. If you have also visited your primary care provider, optometrist, or ophthalmologist, their notes are also included.
Insurance Approval Process
Once the information above is collected, it is sent to your insurance company. This is in the form of a pre-authorization request. A pre-authorization request is necessary to see if your insurance will cover upper eyelid surgery. Hearing back from the insurance company can take anywhere from a few days to a few weeks. This depends on your specific insurer. The prompt return of any additional information requested can expedite the process. Follow-up calls are also helpful, within reason.
Your insurer may deny coverage, approve coverage, or partially approve coverage. A denial is not the end of the road, as you can often appeal their decision. Even after the surgery is approved, discuss any potential costs with your insurance provider. You may still be required to pay deductibles and copayments. It is best to get all of this information in writing.
Is Upper Eyelid Surgery Right For Me?
Upper eyelid surgery is designed to remove excess skin and fat from the eyelids. Below are common factors that indicate you are a good candidate for surgery.
- Loose skin on the upper eyelids
- Eyelids that hang over lashes or block vision
- Tired or heavy-looking eyes
Candidates for the procedure should be in good overall health. It is important that patients do not have any serious eye conditions. Any existing medical conditions should be well-managed before surgery. Patients need to be non-smokers. If you do smoke, you must agree to quit before and after surgery. Realistic expectations about surgical results are also necessary. A skilled and experienced oculoplastic surgeon can assess your symptoms and determine if you are a good candidate. If you are interested in moving forward with upper eyelid surgery, contact the team at Leyngold Institute for Plastic Surgery today to schedule a consultation!