Dan Repp, M.D.
Hooded upper lids and sagging lower lids can give you an older, tired appearance and, in many cases, obstruct your field of vision. Fortunately, this can be fixed with a standard outpatient procedure that can improve appearance and vision. Insurance will cover these procedures if the minimum criteria of vision loss are met. However, if the improvements are only related to appearance, the procedure will be considered elective.
Let’s start by looking at this question from the insurance company’s perspective. The insurance company aims 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 “medical necessity” question similarly, relying on a combination of your symptoms, an 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 work or drive?” If you answered yes to either of those questions, insurance may cover your problem. But it’s not enough for your eyelids to interfere with your activities. Insurance companies generally want more information.
Insurance companies often like to see photographs of your eyelids and eyebrows, again to confirm that everything fits together. Most companies look for similar things in the pictures, 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 remember that your insurance company may have its 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 who come to our office have had a side vision test in the past, but generally, those tests were being used for a different reason. The most common reason patients get a side-vision test is to check for an eye condition known as glaucoma. The approach to side-vision testing is quite different for patients with drooping eyelids. 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 that 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 your surgery is not a “medical necessity,” you still have options. One option is to wait and repeat the testing at some point in the future. Since most eyelid surgery is elective, you can 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.
In summary, it’s difficult for us to know whether your insurance company will cover eyelid lifting surgery before evaluating you. I am happy to assess you in person and hopefully help you get a clear answer. Even if the surgery is not covered, you can still get the necessary care.
BIO: Dr. Dan Repp completed a fellowship in ophthalmic plastic and reconstructive surgery and is certified by the American Board of Ophthalmology. He practices at Eye Surgeons Associates’ Bettendorf and Rock Island offices.
The material contained in this article is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider.
