In order for a blepharoplasty to be covered by medical insurance, the eyelid skin must be impairing your field of vision, usually your peripheral, or side, vision. You will need an eye exam proving your lost field of vision as well as photo documentation and a statement on how your droopy eyelids are impacting your daily life.
Full Answer
What are the requirements to have insurance cover blepharoplasty?
May 20, 2019 · Before approving coverage, Medicare considers the following factors when determining if blepharoplasty is medically necessary: • The amount of excess skin on the upper eyelid that is physically visible. • Proof from an ophthalmological examination that you have a minimum of 30 percent, or 12 degrees, of visual field obstruction.
Does Medicare cover blepharoplasty?
Jan 28, 2022 · Medicare will pay for blepharoplasty when certain guidelines are met. The procedure is considered medically necessary, for example, if you are showing physical signs of excessive upper eyelid skin or the results of a visual field test conducted by an ophthalmologist demonstrate a minimum of 30 percent of visual field obstruction.
Does insurance cover blepharoplasty?
Oct 01, 2015 · Medicare does not cover cosmetic surgery or expenses incurred in connection with such surgery (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 20). This medical policy article specifies covered indications, limitations of coverage, and documentation requirements for non-cosmetic blepharoplasty surgery.
Can insurance pay for blepharoplasty?
Apr 26, 2012 · Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Section 1862(1)(10) prohibits payment for cosmetic surgery. Procedures performed only to approve appearances without a functional benefit are not covered by Medicare. CGS has created a Blepharoplasty Fact Sheet.
How does Medicare qualify for eyelid surgery?
This criteria includes:The excess eyelid skin is diagnosed by physical examination.There must be proof of at least 30% or 12 degrees of obstruction of the visual field caused by the underlying medical condition. ... Medicare-approved physicians must state the surgery is medically necessary and/or recommend the procedure.More items...•Oct 12, 2021
When is a blepharoplasty medically necessary?
Typically, an upper-eyelid blepharoplasty can be considered medically necessary when the upper-eyelid skin is drooping down to the extent that it is blocking vision, usually within the superior visual fields.Jun 21, 2021
Will Medicare pay for lower eyelid surgery?
Yes, Medicare. The public health insurance program for people over 65 typically does not cover cosmetic surgery, but for cases in which a patient's sagging eyelids significantly hinder their vision, it does pay to have them lifted.May 28, 2013
What is the test for eyelid surgery?
What is a Ptosis Visual Field Test? A Ptosis Visual Field Test is a test designed to measure how much your eyelids are interfering with your vision. This is done for insurance qualification only. We will test both the right and left eyes 2 times.Jan 15, 2021
Does insurance cover drooping eyelids?
In general, insurance companies do not cover ptosis surgery. However, if your ptosis is severe enough that your eyelids cause a significant visual obstruction and the condition affects your daily living activities, insurance coverage may be offered.Oct 25, 2020
Does insurance cover hooded eye surgery?
Eyelid surgery can also remove loose skin and tissue on the lower eyelids that create puffy bags under the eyes. When performed solely for cosmetic reasons, eyelid surgery is considered to be elective and therefore cannot be covered by medical insurance.Sep 9, 2017
What is excess eyelid skin called?
Excess Eyelid Skin (Dermatochalasis) Most commonly found in patients over 50 years of age, dermatochalasis is a condition involving excess skin of the upper and lower eyelid.
How much does eyelid surgery cost?
The average cost of cosmetic eyelid surgery is $4,120, according to 2020 statistics from the American Society of Plastic Surgeons. This average cost is only part of the total price – it does not include anesthesia, operating room facilities or other related expenses.
Does Medicare pay for brow lift?
Medicare does not offer coverage for cosmetic surgery. But the program does pay for eyelid lifts, known as blepharoplasty, when a patient's sagging eyelids hinder their vision. Medicare reimbursement for eyelid surgery ranges from $574 to $640 per eye—not exactly a big ticket item.May 30, 2013
Are you awake during blepharoplasty?
In an Awake Blepharoplasty, patients are completely conscious during the procedure. The local anesthesia is usually paired with a soothing sedative to help the patient stay calm and relaxed.
What kind of doctor should I see for eyelid drooping?
Your ophthalmologist determines the type of ptosis based on your medical history and the results of the comprehensive eye exam the doctor may have performed. You may then be referred to an oculoplastic specialist—an ophthalmologist with advanced training in plastic surgery of the eyes and surrounding areas.
Why do my eyes look smaller after blepharoplasty?
The eyes appear asymmetrical Having mismatched or asymmetrical eyelids after blepharoplasty is a common mistake that can occur with Eye Lid surgery. It can occur due to the tissues having been over-excited – or simply due to natural changes in the way each eye responded to surgery or to healing processes.Nov 8, 2019
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Article Guidance
Abstract:#N#Blepharoplasty may be defined as any eyelid surgery that improves abnormal function, reconstructs deformities, or enhances appearance and may be either reconstructive or cosmetic (aesthetic).
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
What is blepharoplasty surgery?
Blepharoplasty may be defined as any eyelid surgery that improves abnormal function, reconstructs deformities, or enhances appearance. It may be either reconstructive or cosmetic (aesthetic). When blepharoplasty is performed to correct visual impairment caused by drooping of the eyelids (ptosis); repair defects caused by trauma or tumor-ablative surgery (ectropion/entropion corneal exposure); treat periorbital sequalae of thyroid disease and nerve palsy; or relieve the painful symptoms of blepharospasm, the procedure should be considered reconstructive. This may involve rearrangement or excision of the structures with the eyelids and/or tissues of the cheek, forehead and nasal areas. Occasionally a graft of skin or other distant tissues is transplanted to replace deficient eyelid components. Surgery of the upper eyelids is reconstructive when it provides functional vision and/or visual field benefits or improves the functioning of a malformed or degenerated body member, but cosmetic when done to enhance aesthetic appearance. The goal of functional restorative surgery is to restore significant function to a structure that has been altered by trauma, infection, inflammation, degeneration (e.g., from aging), neoplasia, or developmental errors.
What is SSA Title XVIII?
Title XVIII of the Social Security Act (SSA): Section 1862 (a) (1) (A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Document Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
CMS National Coverage Policy
Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy.
Coverage Guidance
Abstract:#N#Medicare does not cover cosmetic surgery or expenses incurred in connection with such surgery.
What is a visual field test?
A visual field test is performed that demonstrates a defect in vision due to the excess upper eyelid skin, and then that test is repeated with the eyelids taped up to show improvement in vision if the eyelids are lifted.
Is blepharoplasty covered by insurance?
Answer: Insurance requirements for blepharoplasty. Yes, it is definitely possible to have upper eyelid blepharoplasty covered by insurance. Lower eyelid blepharoplasty, however is not covered by insurance. For the upper eyelids: 1.
Looking for answers about whether Medicare covers blepharoplasty? Medicare never covers the cost of any cosmetic procedures, but there are some cases when blepharoplasty is medically necessary. If blepharoplasty is medically necessary, then Medicare will cover the costs. Read on to learn in which scenarios Medicare will and will not cover the cost of blepharoplasty surgery
D. Gilson is a writer and author of essays, poetry, and scholarship that explore the relationship between popular culture, literature, sexuality, and memoir. His latest book is Jesus Freak, with Will Stockton, part of Bloomsbury’s 33 1/3 Series. His other books include I Will Say This Exactly One Time and Crush.
Does Medicare or Health Insurance pay for cosmetic surgery?
Medicare will never pay for cosmetic surgery, and whether or not your health insurance will depend on the provider and the insurance plan. Most health insurance policies, however, will only pay for the procedure if it is classified as “reconstructive” and not “cosmetic” in most circumstances.
Can I combine eyelid surgery with other procedures?
You can combine various eyelid procedures with other procedures. These other procedures are often cosmetic surgeries as well, and opting to get blepharoplasty at the same time could change the overall outcome.
Out-of-Pocket Costs
If your blepharoplasty was deemed to be medically necessary, and you did not get any additional procedures, then there should be no out-of-pocket costs. We still recommend that you always check with your actual health insurance provider. They might have specific criteria that you must meet in order to cover the costs.
What is a visual field test?
A visual field test is a noninvasive way to evaluate peripheral vision. This test is usually performed at an ophthalmology office. The field of vision is tested both with the eyelids in their natural position and with them held up (usually with tape). The difference between the taped and untapped visual field determines whether or not insurance ...
Does insurance cover eyelid surgery?
The difference between the taped and untapped visual field determines whether or not insurance will cover upper eyelid surgery. The visual field must improve by a certain percentage or certain number of degrees depending on the insurance carrier. Occasionally there are other indications that insurance companies will accept to cover upper eyelid ...
Is ptosis repair covered by insurance?
To put it another way, if the upper lids block enough of your vision to significantly affect your life, then blepharoplasty or ptosis repair is considered medically necessary and may be covered by insurance. So what are the criteria that insurance companies use to determine if blepharoplasty or upper eyelid surgery is “visually significant”, ...
Does Medicare cover ptosis?
In general, insurance companies will cover blepharoplasty or ptosis repair if the eyelids cause a “visually significant” obstruction of the upper visual field that “affects activities of daily living”.
How much does a blepharoplasty cost?
The average cost of a blepharoplasty is over $3,000. This cost does not account for operating room facilities, anesthesia, and additional expenses related to the procedure. Even when the blepharoplasty is covered by insurance, there are usually out-of-pocket expenses involved.
What are the benefits of blepharoplasty?
Functional blepharoplasties are covered by most major medical insurance companies when the excess eyelid skin impairs your functional vision. The following are examples of when a blepharoplasty can be deemed medically necessary and therefore covered by medical insurance: 1 Your upper and/or outer visual fields are significantly impaired, and the visual field can be improved by at least 15 degrees. 2 Corneal or conjunctiva irritation is caused by the drooping eyelids. 3 Repair for lax muscles is needed due to ptosis. 4 You have difficulty tolerating a prosthetic due to your upper eyelid position. 5 Repair defects are present, caused by tumor-ablative surgery or trauma. 6 You need the surgery to relieve chronic dermatitis, caused by too much eyelid skin that does not respond to alternative treatments. 7 You need relief for painful or visual symptoms of blepharospasm.
What is the procedure to remove sagging skin under the eyes?
A blepharoplasty is one of the most common cosmetic procedures to reduce signs of aging around the eyes, such as droopy eyelids, sagging skin, wrinkles, and bags under the eyes. The procedure removes excess skin, muscle, and fatty tissue that can cause your eyelids to droop.
Does medical insurance cover eyelid lifts?
It can be done on the upper or lower eyelids, or on both. Medical insurance does not cover the cost of cosmetic procedures or surgery.