Is Eyelid Surgery Covered by Insurance?

How do Insurance Companies Determine If Blepharoplasty Is Medically Necessary?

Insurance companies consider blepharoplasty or upper eyelid surgery medically necessary when the patient can provide the following evidence-

Physician Notes

The physician notes must clearly document- eyelid positions, reduced visual field, and the patient’s complaint about upper eyelids interfering with the regular activities, such as driving, reading, etc. The eyelid position must be measured by the physician using standard oculoplastic techniques and the margin to reflex distance 1 (MRD1). 

The margin reflex distance 1 is the metric that is used to determine the degree of ptosis or retraction of the upper eyelid. It involves directing light at the patient’s eye and the distance between the directed light reflex on the cornea and the center level of the upper eyelid margin. The MRD1 value should be less than 2 mm. 

External Ophthalmic Photography

Multiple high-resolution photographs of the eyelids and eyes should be taken that clearly indicate that the eyelids cover a significant part of the cornea and impair vision. The photos should also evidently clarify that the eyelid skin falls within less than 2 mm of the center of the pupil. 

Visual Fields

A detailed report of the visual field test should be submitted that evaluates the peripheral vision of the patient. The test is non-invasive and performed at the doctor’s office or clinic. The field of vision is first tested by placing both eyelids in their natural position. Then the eyelids are held up with the help of tape.

The difference between the taped and untaped visual field is noted and used to determine whether or not the insurance policy will cover the upper eyelid surgery.

Expenses Covered by Health Insurance Plans for Blepharoplasty

Various expenses that are covered by health insurance policies, in general, include the following-

• Hospitalization expenses, including admission fee, bed charges, room rent, medical consumables, ICU charges, OT charges, anesthesia cost, nursing fee, meal charges, etc. 
• Pre and post-surgery hospitalization expenses, including doctor consultations, diagnostic tests, post-op follow-ups, etc. 
• Ambulance cost, usually up to Rs. 2,000. 
• Cost of medications prescribed to the patient during the hospital stay. 
• Surgeon, attending surgeon, and anesthetist’s fee. 
• Cost of implants, if any. 
• Second opinion from a doctor.

Insurance policies can also be customized according to the patient’s needs to cover extra expenses so that they can optimal care without worrying about the expenses. However, there will be some standard exclusions. To learn more about the exclusions, it’ll be best to talk to the insurance provider.