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Can my upper eyelid surgery be covered by my insurance?

Occasionally we see patients who come in for a consultation for upper eyelid surgery or blepharoplasty and question whether their insurance will cover this procedure.  Oftentimes, there is a combination of several issues.  One is brow ptosis, where the eyebrows may be dropping below the orbital rim and pushing the eyelid skin down.  The second is dermatochalasis, or excess skin of the upper eyelids, that can be covering the eyelashes or pushing the lashes down.  This oftentimes causes more problems with upward gaze as well as problems with peripheral vision.  In addition, there is a term called ptosis, which means droopy eyelids.  There are two muscles of the upper eyelid that are predominantly responsible for lifting the upper eyelid.  This muscle can weaken with aging.  If there is evidence of ptosis of the eyelids, that is, the lids are blocking the pupil, decreasing the field of vision and causing problems with eye strain and eye fatigue, a blepharoplasty and ptosis repair may be covered by insurance.  Oftentimes, these patients may complain of heaviness of the eyes, difficulty with reading for long periods of time, having to constantly tighten the forehead muscles in order to see better, difficulty with peripheral vision, most noticeable when driving.  A visual field test is performed with and without taping of the eyelids to their normal position.  Most insurance companies require a 25 – 30% improvement in the field of vision in order for surgery to be considered medically necessary.  At the time of your consultation, it is very important that you describe to the physician the difficulty that you are having with the eyes as far as interference with activities of daily living, reading, driving, etc.  The physician will examine the eyes and adjacent structures and make a decision whether visual field tests would be needed as well as a potential pre-determination letter to your insurance company.

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