Is Eyelid Surgery Covered By Insurance?

Heavy eyelids, sagging skin, and excess fat deposits can all prematurely age the eyes. These types of imperfections often garner comments that a person looks tired or upset.

Fortunately, eyelid surgery addresses signs of aging around the upper and/or lower eyelids to restore a more youthful and refreshed appearance.

Eyelid surgery offers promising results, but it does come with a cost. People considering eyelid surgery with facial plastic surgeon David A. Sherris often ask if insurance will cover eyelid surgery.

We are happy to help individuals from Buffalo, NY, Rochester, NY, Niagara Falls, and surrounding areas explore their need for surgery and their insurance coverage to determine whether it may cover all or part of the cost of eyelid surgery.

What Is Functional Eyelid Surgery?

Eyelid surgery is commonly performed to enhance facial appearance. The procedure trims excess skin and fat on the upper eyelids to create a younger-looking appearance. Eyelid surgery can also remove loose skin and tissue on the lower eyelids that create puffy bags under the eyes.

When performed solely for cosmetic reasons, eyelid surgery is considered to be elective and therefore cannot be covered by medical insurance.

Eyelid surgery can be covered by medical insurance if it is deemed medically necessary. Functional eyelid surgery removes heavy skin that hangs over the eyelash line, interfering with the line of sight.

Impaired vision caused by excess, hanging upper eyelid skin can make everyday activities such as driving, reading, and sending text messages difficult.

Most insurance companies require proof in the form of a visual test in order to determine coverage for eyelid surgery. The vision test needs to be performed by a board-certified eye doctor, such as an oculoplastic surgeon.

If the vision test determines there is visual impairment, the surgeon takes pictures of the condition and sends them to the patient’s insurance provider. Whether the insurance company covers all or a part of the cost for eyelid surgery depends on the patient’s specific coverage plan.

Insurance Coverage for Cosmetic Procedures

Insurance coverage is meant to cover the cost of appointments, treatments, and procedures that are medically necessary. This means that no matter what type of insurance coverage a person has, they should not expect it to cover the cost of cosmetic procedures or those that are elective.

In general, eyelid surgery is considered an elective procedure because it primarily addresses cosmetic concerns. If eyelid surgery is being performed for purely aesthetic reasons, then patients should not expect insurance coverage, meaning they will need to cover the cost of treatment on their own.

Most people run into the issue of not having their eyelid surgery covered by insurance. This is because it is considered a cosmetic procedure, and those procedures are not covered by insurance plans. The only exception to this rule is breast reconstruction following a mastectomy, which is protected by law.

Routine anti-aging procedures, such as eyelid or brow lift surgery, are seen as cosmetic improvements only and cannot be paid for using medical insurance.

This patient had weakness in both of her eyelids, worse on her right. Both eyelid muscles were tightened (ptosis repair) and a crease was placed. Note that the eyelashes no longer point downward and that the vertical opening is greater than preoperatively.

Is Eyelid Surgery Medically Necessary?

While eyelid surgery addresses many cosmetic concerns, such as heavy, sagging eyelids and bags beneath the eyes, there are times when the procedure can be medically beneficial.

If a person is able to demonstrate that eyelid surgery is medically necessary, then insurance coverage might pay for all or part of the procedure. If a person applies for insurance coverage for their eyelid procedure they will need to have proper documentation that it is medically necessary.

To demonstrate the need for eyelid surgery, patients have to work with a doctor, typically an optometrist. The optometrist needs to document that there are medical issues present that can be corrected through eyelid surgery.

Most commonly, eyelid surgery is performed to treat obstructed vision due to overly heavy or hooded eyelids or to address concerns such as inflammation or poor eyelid function. In addition to written documentation from a medical provider, insurance companies may also request photographs of the condition before approving coverage.

Sagging eyelids can have a significant impact on your appearance as well as your comfort. Both men and women are likely to develop ptosis of the eyes as they age because the surrounding skin and muscles become weakened. There are also instances where this ptosis is present due to a congenital disability or trauma to the eye.

According to the American Society of Plastic Surgeons (ASPS), the average cost of eyelid surgery is $3,026. This price can fluctuate depending on the geographic area, the skill of the surgeon, and other associated fees, such as local or general anesthesia. But can these costs be mitigated by going through your insurance?

Medical Ptosis

There are some cases where the ptosis of the eyelid can be classified as a medical issue. Eye ptosis in adults is caused by the levator muscles stretching and separating from the eyelid.

If this issue becomes significant enough to obstruct your vision, then part of your surgery may be covered by insurance.

To obtain coverage, your doctor will first need to evaluate your condition and determine if drooping lids are causing vision impairment. If this is the case, your doctor will submit their recommendation to your insurance company.

In most cases, they will only approve the minimum treatment necessary to fix the medical issue. Cosmetic procedures, such as skin tightening, fat redistribution, or a brow lift, will likely be additional out-of-pocket costs.

Should You Undergo Eyelid Surgery?

If your eyelid ptosis is severely affecting your confidence and overall quality of life, you should schedule a consultation with a board-certified plastic surgeon to discuss your treatment options.

Even if your surgery isn’t covered by insurance, there are financing options available through CareCredit® to help make your procedure more affordable.

Eyelid Surgery Payment Options

If insurance coverage does not apply to eyelid surgery, or if only a portion of the procedure costs is covered, there will be out-of-pocket expenses for the patient. Covering these costs can put a strain on a person’s finances, but there are alternate payment options to consider.

Many finance companies offer loans and/or credit cards that are specifically meant to cover the costs of medically necessary or elective cosmetic procedures. Our financing team can work with patients to find a payment option that works within their budget.

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