Can I Use Medical Insurance For Upper Eyelid Surgery (Blepharoplasty/Ptosis Repair)?
Upper Blepharoplasty and Ptosis Repair can be an Insurance Authorized Benefit
If you meet the criteria for medical necessity in your insurance policy, you can use medical insurance for upper eyelid surgery (upper blepharoplasty and ptosis repair). Medical insurance cannot be used if the primary goal is to improve appearance. Some policies completely exclude upper blepharoplasty and ptosis repair. If you are unsure, contact your insurance company for guidance. Insurance companies will not reimburse both upper blepharoplasty and ptosis repair when done in the same surgical setting. One of the two will be considered self pay if a patient has both upper blepharoplasty and ptosis repair in the same surgical setting.
Medical Necessity Criteria
Medical necessity criteria will vary depending on the insurance policy. Most commonly, upper blepharoplasty and ptosis repair may be considered medically necessary if the eyelids affect vision/peripheral visual field in a way that impacts activities of daily living (e.g. driving, reading, phone and computer use).
Documentation
For most insurance companies, there are three types of documentation that are required: 1) clinical exam notes, 2) visual field testing, and 3) high resolution color photographs. If you’ve had a visual field done elsewhere, bring this with you to the appointment or have the visual fields sent to us. We will review any previous records with you at the appointment. Medicare does not require visual field testing, however visual field testing has been required by all other insurance companies/policies we have worked with.
In Network vs. Out of Network
We are in network with major medical insurance companies. You can see a full list here. You can also verify with your insurance company directly. If we are in network, we will help with insurance authorization as noted below. For out of network patients, we use self pay rates as noted here. If you are out of network, upon request, we can provide documentation should you wish to attempt to submit a claim directly to your insurance company for reimbursement. However, it is important to note, that, in our experience, patients may find it challenging to obtain reimbursement for out of network services.
Insurance Authorization
Once we have the necessary documentation, if you meet medical necessity criteria and we are in network with your insurance plan, we will work with your insurance company to submit your case for prior authorization. We will obtain a decision from your insurance company and will inform you of the authorization status prior to performing any surgery. If your surgery is denied by insurance, we offer self pay surgery with prices as listed here.
Costs
If the surgery is authorized by your insurance company this does not necessarily mean that the insurance covers your financial costs. Your out of pocket costs for office visits and surgery will depend on your specific medical insurance plan. Costs may include co-pays, unmet deductible amounts, and coinsurance. For surgeries through medical insurance, there are three claims: 1) surgeon’s office claim, 2) facility claim, and 3) anesthesia claim. Prior to surgery, we prepare an estimate for the surgeon’s claim. This amount is paid prior to surgery. Once the explanation of benefits comes back from your insurance company, any necessary adjustments (refunds, collecting additional balance) will be made after we share this information with you. Prior to surgery, we also provide patients with the necessary information to obtain estimates for the facility and anesthesia fees depending on the location of surgery as well as the insurance plan.
Insurance Based Upper Eyelid Surgery can be combined with Cosmetic Surgery
Cosmetic or self pay surgery can be performed in the same surgical setting as an insurance based surgery. Common combinations include insurance based upper blepharoplasty with self-pay ptosis repair and insurance based upper blepharoplasty with self pay/cosmetic lower blepharoplasty.
Learn more about Upper Blepharoplasty and Ptosis Repair
You can learn more about upper blepharoplasty on our website here. You can learn more about ptosis repair on our website here. You can see before and after photos here.
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