Being one of the most often performed cosmetic and functional surgeries, eyelid surgery is an extraordinary kind of business. It may be beautiful eyelid surgery, and under some circumstances, patients may go as far as to say that droopy eyelids pose a threat to their eyesight.If you ever wonder whether there is any procedure to middleman insurance to pay for an eyelid surgery, you are not alone!
Many patients feel lost in the entire process, but with appropriate documentation and approach, coverage can be secured. The whole gamut of important information on eyelid surgery will be provided; what steps to follow to have eyelid surgery considered by the insurer, what to do in case of a denial for the procedure, and the ostensible out-of-pocket cost. The article ends with some pointers to hopefully help promote success.
Understanding Eyelid Surgery (Blepharoplasty)
Before venturing into ways to get insurance to pay for eyelid surgery, one ought to fully understand better what the procedure is and why it is done.
What Is Blepharoplasty?
Blepharoplasty is a surgical procedure that removes excess skin, muscle, sometimes fat, from the upper or lower eyelids depending on the need.The purposes may be:
- Functional-The procedure is done to improve sight obstructed by drooping eyelids (ptosis).
- Cosmetic-For puffiness, sagging, or just tired looks.
Functional Versus Cosmetic Eyelid Surgery
Usually, insurance covers eyelid surgery mostly when it is done for functional reasons; however, it seldom covers cosmetic eyelid surgery.
- Functional Blepharoplasty – Is when drooping eyelids interfere with your visual field to some extent or cause headaches from the constant lifting of eyebrows or perhaps skin irritation on one’s face.
- Cosmetic Blepharoplasty – For any of a variety of reasons, the most famous being the improvement of appearance feeding down aging or changing eye shape.
Common Medical Reasons for Eyelid Surgery
If you want to know about insurance coverage for an eyelid surgery, ubiquitously speaking, your case should be under the category of medical necessity.Common reasons include:
- Significant drooping that reduces the upper field of vision
- Eyelid skin causing eye strain or headaches
Regular irritation resulting from rubbing of eyes by the skin
How to Get Insurance to Pay for Eyelid Surgery
The key to securing insurance approval is demonstrating medical necessity. Here’s a step-by-step outline.
1. Have an Eye Exam with a Qualified Ophthalmologist
In the very first step of how to get insurance to pay for eyelid surgery, there should be a thorough eye examination.
The doctor will measure margin reflex distance (MRD) — the distance from the center of the pupil to the upper eyelid.
If it measures 2.0 mm or less, it is likely to be deemed by many insurance companies as functionally impaired.
2. Document Visual Field Loss
- Visual field testing is usually required by most insurance carriers.
- You look into a machine that maps peripheral vision.
- Tests are done before and after lifting your eyelids with tape.
- If there is significant improvement after lifting, this works in your favor.
3. Take Clinical Photographs
How to get insurance to pay for eyelid surgery requires having clear photographs.
- The images must show the eyelid overlapping the pupil.
- Photos should not be taken by the patient; a medical professional must take them.
4. The Letter
Procedure doctors and ophthalmologists must write a letter stating:
- Diagnosis: ptosis, dermatochalasis
- Symptoms: Obstruction of vision, headaches, eye strain
- Tests proving impairment
- Methods by which surgery would rectify the problem
5. Preauthorization Request Submission
Once packing a surgery, all documents have to be submitted to the insurance company by your provider:
- Visual field test results
- Photographs
- MRD measurements
- The medical necessity letter
Going for the surgery without preapproval means you may have to pay out of pocket in case the procedure is later judged to be necessary.
6. Preparing to Appeal
Insurance companies sometimes withdraw coverage, in spite of your diligence in keeping every step. In this case:
- Request a written explanation of the denial
- Produce additional evidence
- Appoint your doctor to write a stronger appeal letter
- Go for a second opinion
Costs if You Pay Out of Pocket
If you cannot get insurance approval, you need to pay for the surgery yourself. Having an outlook on the cost prepares one financially.
Average Cost of Eyelid Surgery:
- Upper eyelids only: $3,000 to $4,500
- Lower eyelids only: $2,500 to $4,000
- Both upper and lower eyelids: $5,000 to $7,000
What Is Included in the Cost
- Surgeon’s fees
- Anesthesia
- Operating facility costs
- Follow-up visits
Reasons Why Prices Vary
- Location- Surgeons in larger cities generally charge more
- Surgeon Experience- The more experienced, board-certified surgeon often charges higher fees
- Procedure Complexity- Corrections that are more extensive cost more
Options for Financing
If you could not get the insurance to pay for it, you might try:
- Medical credit cards such as CareCredit
- Financing through the surgeon
- Personal loans
- Health savings account (HSA) or flexible spending account (FSA)
Tips to Increase Your Chances of Insurance Approval
Getting insurance to pay for eyelid surgery hinges on presenting a strong and evidence-backed case.
1. Keep a Symptom Diary
Daily time documenting struggles:
- Holding eyelids to read with fingers
- Trouble with driving due to blocked vision
- Eye fatigue or headaches after short spell periods
2. Use Specific Medical Terms
Being specific with medical language regarding symptoms can help you with your doctor:
- Instead of saying “I look tired”, you might say “My eyelids block my peripheral vision and cause eye strain.”
3. Meet All Documentation Requirements
Insurance companies can only be strict with guidelines. Missing one document will result in denial.
4. Use a Provider Experienced with Insurance Cases
Some surgeons specialize in functional blepharoplasty and know exactly how to get through insurance companies.
5. Do Not Skip the Visual Field Test
Even though your eyelids would show obvious signs of drooping, insurers still demand the results of the tests as proof.
6. Request Peer-to-Peer Review
Your doctor can request a peer-to-peer review with your insurance company’s medical or surgical director(s) to talk about the reasons for denial and make an argument about why the surgery should be covered.
7. Keep Fighting
Approval is usually given after appeals. Be patient and complete.
Conclusion
There is much more in learning how to get insurance to pay for eyelid surgery than simply presenting a claim-it requires proving strong medical necessity. To increase the odds of getting reimbursed, one needs to document symptoms, undergo appropriate tests, present photographs, and coordinate the process with an experienced provider.
If a denial occurs, do not concede. Instead, appeal, add more supporting evidence, and remain steadfast since more often than not, persistence does prevail.
Frequently Asked Questions (FAQs)
1. How to get eyelid surgery paid for by the insurance company if my main concern is appearance?
If the eyelids are only a problem cosmetically and do not affect the actual vision, insurance may not offer coverage for the operation. You will have to pay for it yourself.
2. What static tests are needed to secure insurance for eyelid surgery?
Insurers require LGN visual field, MRD measurements, and medical photographs for most of their policies.
3. How long does insurance approval take for eyelid surgery?
Approval could be 2-3 days or 2-3 weeks, depending on the insurance company involved.
4. Does Medicare pay eyelid surgery?
Yes, if the surgery is deemed medically necessary by Medicare, usually evidenced by documented visual field loss and MRD measurements.
5. Is there an appeal procedure in case my eyelid surgery claim gets denied?
Yes. In the appeal process, you will be allowed to provide additional documentation and participate in a peer-to-peer review involving your treating physician and the insurer’s medical reviewer.
Thinking about eyelid surgery? Discover how to qualify for insurance coverage and reduce out-of-pocket costs with our easy guide! For any query, contact USInsurance247.
