Many doctors and patients are unsure if blepharoplasty or ptosis repair is covered by insurance and when. This article is an update and serves to help understand the criteria for coverage.
In 2025, for blepharoplasty or ptosis repair to qualify for insurance coverage, the procedure must be deemed medically necessary rather than cosmetic. Dr Thiagarajah has performed roughly ten thousand eyelid procedures. It is important to know the surgeon doesn't decide if insurance covers upper eyelid surgery but is based on a fixed criteria. The criteria are generally based on Medicare and insurance carrier guidelines, which include the following requirements:
Documented Visual Impairment: The drooping eyelid skin must obstruct the upper visual field significantly, impairing daily activities such as driving or reading. This is typically demonstrated through:
Physician notes detailing the eyelid position and its interference with vision or activities.
High-resolution photographs showing eyelid droop (less than 2mm from the pupil in many cases) If this criteria is not met, insurance will not cover it regardless if all other criteria (visual field/symptoms etc) are met
Visual field testing showing at least a 15-degree improvement in peripheral vision when the eyelids are lifted.
Impact on Health or Function: Insurance also requires some impact on activites of daily living from the drooping eyelid such as driving, reading, cooking, walking etc. The patient needs to have some complaint.
Pre-authorization Process: Supporting documentation, including physician assessments, photos, and test results, must be submitted for insurance pre-authorization. Medicare does not pre-authorize but relies on well-documented medical necessity assessments.
Examples:
Case 1: This patient has loose skin within 2 mm of the center of the eye (white light reflex). If they had symptoms it would qualify for insurance coverage in most cases
Case 2:
This patient has loose skin 4 mm from the central light reflex of the eye. Even if they had visual field defects on field testing or symptoms (ie I have trouble seeing), insurance would NOT cover this patient because the skin is not bad enough.
Case 3: This patient is interesting because she has one eye which has loose skin within 1 mm of the central light reflex and the other eyelid skin is 3.5 mm. Her right eye (left in the picture) would be covered by insurance and her left eye would not. Insurance doesn't cover eyelids to match etc.
One important thing to note is that removal of loose skin is not covered in ptosis repair unless it is believed that not removing the loose skin would create the need for a secondary covered functional surgery. The patient would need to have enough loose skin if the eyelid was opened that the skin would bunch up and hang over the eyelid edge within 2 mm of the center of the pupil
Cosmetic procedures performed to enhance appearance without functional impairment are not covered. "I feel I look tired" or "I don't like how I look" are not functional complaints for insurance coverage.
Hopefully this is a good summary to help doctors who send patients to me. My practice performs 1000s of upper eyelid surgeries but it is good for referring doctors and even patients to understand the guidelines for counseling.
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