Introduction – The Expense of Eyelid Surgery
Many people undergo eyelid surgery, also known as blepharoplasty, to enhance their looks and vision, and it certainly helps in those regards. But, as with many things in life, there is a price to pay. While blepharoplasty is an outpatient surgery, the costs can vary from $3,000 to $6,000 depending on the region and the specialist. Those costs will be even greater if the surgery is labeled as cosmetic surgery by the insurance, as it will be an out of pocket expense.
The positive aspect is that you can turn the surgery into a medical necessity and your insurance will help out. Let’s examine how to turn insurance-covered, out of pocket surgery step by step from cosmetic to medical.
Understanding Eyelid Surgery (Blepharoplasty)
What Eyelid Surgery Involves
Blepharoplasty is a surgical procedure that removes excess skin, muscle, and fat from above or below the eyelids. The reasons people undergo this surgery is to either appear younger, or to gain more self-esteem as sagging eyelids can impair vision.
Cosmetic vs. Functional Eyelid Surgery
- Cosmetic Eyelid Surgery: It’s purely for aesthetic reasons such as the removal of puffy bags, smoothing wrinkles and tightening the skin.
- Functional Eyelid Surgery: It is corrective surgery undertaken to treat a medical condition like eyelids drooping into the field of vision or discomfort.
The insurance claims will only pay for functional eyelid surgery and covering your case is everything.
Why Cosmetic Surgery Is Typically Not Covered By Insurance
Insurance Guidelines and “Medical Necessity”
Insurance companies follow specific guidelines regarding coverage. For cosmetic procedures, they won’t cover anything designed purely for aesthetic purposes. To gain approval, it is necessary to show the surgery is required for health improvement or maintenance.
Common Reasons For Denial
- No documented evidence of vision impairment
- No documented evidence of associated medical conditions
- Insufficient documentation, testing, or records
- Incorrect submission of diagnosis/procedure codes
When Eyelid Surgery Is Viewed As A Medical Necessity
Here’s the thing: insurance companies are not discriminatory to eyelid surgery. They only need it to be medically justified to reimburse the costs.
Droopy Eyelids That Block Peripheral Vision (Ptosis)
Patients who have upper eyelids that droop are considered functional if it limits some of their eyesight. There are many insurance companies that follow a guideline that if the eyelids obstruct 20-30% of the visual field, there is a possibility of coverage.
Chronic Skin Irritation or Eye Infections
Sagging eyelids could be the result of excess skin folds which can be used to argue for the overgrowth of moisture which leads to some kind of skin infections.
Forehead Headaches and Eye Fatigue
If you are constantly lifting your eyelids to see, it may lead to forehead headaches, eye fatigue, and other ailments, which insurance companies would approve for reimbursement.
Getting Insurance Approved: A Simple & Effective Approach
Step 1: Keeping Track of Your Symptoms
Make and maintain symptom log: blurry vision, headaches, eye strain, and skin irritation. The log should be as detailed as possible.
Step 2: Book An Appointment With An Ophthalmologist To Have Your Eyes Examined
Go to an ophthalmologist or an oculoplastic surgeon. They are qualified to check whether droopy eyelids are obstructing vision.
Step 3: Order a Visual Field Examination
This test checks the range and sensitivity of the vision. If significant blockage is detected, then you have solid evidence to present to the insurance.
Step 4: Collect Medical History and Pictures
Insurance companies love before-after comparisons. Clear, unedited photos of the eyes showing the eyelid droop enhance the claim significantly.
Step 5: Submit Insurance Pre-Authorization
Your doctor’s office is submitting the photos, medical notes, and test results as an insurance pre-authorization claim to the insurance company prior to surgery.
Collaborating With Your Physician To Strengthen The Insurance Claim
Detailed Medical Claim Reports With Insurance Policies
Request your medical practitioner clearly outline how droopy eyelids affect daily activities: driving, computer work, and reading.
Before-and-afters Photos for Tyrosine Hydroxylase
Several clinics offer virtual simulations of the post-TH surgery appearance. While the skin removal is done for cosmetic purposes, the procedure is done to enhance the vision.
How to Appeal Denied Insurance Claims
Reviewing The Denial Letter
Hearing a “no” from your insurance can be concerning, however, you can ease your worries by looking deeper into their denial letter. Such letters are revealing as to the reasons a claim was denied, be it related to missing information, lack of coverage, or untimely submission.
Filing An Effective Appeal
Within a claim, there are multiple reasons as to why it can be denied, and addressing them can often be a lengthy process. Often it is recommended that you work with your healthcare provider to tackle the insurer’s reasons. This can be resending test results, sending photographs, issuing more granular notes, or limiters sections that are specific.
Consulting a Patient Advocate or Specialized Lawyer
For more complex claims, the option to hiring a patient advocate or a specialized medical insurance lawyer becomes available. Although hiring specialized personnel can lead to increased costs, it becomes justified for complex and expensive surgeries as it can pay off in the long run.
Rules Regarding Medical Insurance Coverage
Have Full Command Over Your Insurance Policy
Your insurance policy is your guide, and the policies are documents such as limitation of insurance and medical assessment policies with info on reconstructive surgery and vision impairment. In case of ambiguous issues, you can directly call their number.
Medical Codes
Medical codes are often compared to passwords as the wrong medical code can have your claim denied status. Medical codes are not to be taken lightly as the wrong codes can have detrimental effects.
Politeness
Filing claims can be a long and slow process, and patience can lack easily during it. Keeping your cool during the process is of utmost importance, and remaining calm can have quantifiable pay offs due to regulations and calmness.
Successful Coverage
- Case Study 1: 56 year old woman with daily headaches resulting from lifting of her brows. Field visual testing verified a 35% vision loss and insurance approval was given.
- Case Study 2: A man suffered chronic eyelid dermatitis due to persistent skin folds. The man had photographs and notes from his dermatologist. Coverage was granted due to medical necessity.
The Bottom Line On Insurance and Eyelid Surgery
Convincing insurance providers to cover eyelid surgery requires showcasing medical justification. The more proof beyond bare minimum photos and records you bring, the better. The word “cosmetic” should not deter you from trying to obtain insurance coverage. You have the option to flip the procedure from out-of-pocket to insurance covered with the right steps.
Conclusion: “Cosmetic” Becomes “Covered”
Eyelid surgery can bring remarkable change to one’s life, especially regarding vision and everyday comfort. Insurers may initially refuse coverage, but with proper documentation and unwavering resolve, they can be persuaded. Your health makes the effort worthwhile, so put in the work.
Understanding how to get insurance to pay for eyelid surgery can be tricky, just like navigating other coverage questions. You might also be curious about do chiropractors take insurance or how much is a colonoscopy without insurance as part of managing overall healthcare costs.
FAQs About Insurance to Pay for Eyelid Surgery
What is the average out-of-pocket cost for eyelid surgery?
The cost of eyelid surgery ranges $3,000 to $6,000 based on geography and the experience of the surgeon.
Is it possible for Medicare to cover eyelid surgery?
Certainly. If medical necessity can be established with vision tests and clinical documents, coverage can be approved.
What is the average time to receive insurance approval?
Approval can take anywhere from two weeks to two months based on the insurer’s review process.
Do I need simultaneous consultations?
Not always, but a second opinion may help if your physician’s documentation is insufficient.
And if my insurance only covers a portion of the expenses?
Appeal for full coverage or pay the remaining balance out-of-pocket.
