Eyelid Surgery: What does my insurance pay for, and what is cosmetic?

By Joseph Walrath, MD | Oct 29, 2014 | Blepharoplasty, Cosmetic, Eyelid Malposition, Ptosis, Reconstruction

Insurance is always changing, and patients better believe that covered benefits are only going to lessen, not increase, over time.  If a patient truly believes that their eyelid condition is affecting their vision in a meaningful way, it is critical to see a surgeon who is familiar with insurance reimbursement for eyelid surgery.  Generally speaking, that type of surgeon is an oculoplastic surgeon. That type of surgeon can not only talk intelligently about the risks of surgery, but he or she can also talk intelligently about the financial risks of surgery.  Plainly stated, it’s important to understand your likelihood of getting stuck with a bill at the end of the day.

Here is a recent example of a patient who has visually significant upper lid droop (ptosis).


It is clear from the photo that the upper lids are impacting her ability to see.  All of the diagnostic testing was performed during the initial office visit so that all of the evidence for her medical claim could be rapidly submitted to her insurance.  Submission of all of this data led to insurance approval for upper lid ptosis repair.  She is seen postoperatively below, after 4 months:


Notice the light reflex form the camera flash, in the center of the eye (the white spot in the pupil).  It was not present in the preoperative photo, because the lid was so low that the center of the cornea (the clear covering of the front of the eye) was covered by eyelid!

Now look at the lower eyelids.  This patient elected to undergo lower blepharoplasty at the same time as her upper lid surgery.  The lower blepharoplasty was cosmetic and was not appropriate to submit to insurance. For those interested in the technical details, the surgery was done under “twilight” anesthesia (not general anesthesia).  The lower lid fat was removed from inside the lower eyelid and by utiliization of the upper eyelid incision.  A small strip of skin was removed.

Another financial note: There are some modest financial benefits to choosing to have the lower eyelid cosmetic procedure at the same time as the upper eyelid insurance procedure.  This is largely due to a reduced facility rate, the rate charged for OR staff and anesthesiology, for any cosmetic procedures that are done at the same time as insurance procedures.