Eyelid surgery is one of the most popular and commonly performed cosmetic surgeries. Its many variations are designed to improve the appearance of your upper eyelids, lower eyelids, or both. In each case, the surgery addresses the signs of aging, including fine lines, wrinkles, and sagging skin, by removing excess fat and tightening the skin around the eyelids. The procedure results in a facial appearance that appears younger and more rejuvenated, so many people undergo cosmetic eyelid surgery for aesthetic reasons. That being said, the procedure is sometimes considered medically necessary. This has led many to ask the question, “Will insurance cover cosmetic eyelid surgery?” Below, we detail this and more about the procedure.
Will Insurance Cover Cosmetic Eyelid Surgery?
Eyelid surgery is typically performed for aesthetic reasons, though some patients undergo it for medical reasons. The most common questions patients have about the surgery are about the associated costs. More specifically, they wonder whether insurance covers eyelid surgery. The answer depends on why you are getting the surgery because insurance companies will treat elective cosmetic procedures and medically necessary ones quite differently.
Cosmetic Eyelid Surgery
Cosmetic eyelid surgery is specifically done to improve the appearance of the eyes and combat the signs of aging and poor lifestyle habits that can show up on your face and especially around your eyes. These signs are more common around the eyes because the skin around your eyes is much thinner than that on the rest of your face. Complexion issues around the eyes commonly include fine lines, wrinkles, and skin sagging. As stated, these issues are a result of the natural aging process, but poor lifestyle habits can also exacerbate them. Such habits include smoking, excessive drinking, and chronic stress. Poor sleep habits, a sedentary lifestyle, and an unhealthy diet are also impactful.
Eyelid surgery performed to address aesthetic issues is considered cosmetic. Cosmetic procedures are elective and are not covered by health insurance, so patients who get cosmetic eyelid surgery must usually pay out of pocket. Depending on the surgeon, geographic location, the complexity of the procedure, and the type of eyelid surgery, costs can vary. Your surgeon will provide you with payment information during your consultation.
Medically Necessary Eyelid Surgery
Eyelid surgery may also be performed because it is medically necessary. Functional issues with your eyelids can necessitate eyelid surgery. If the surgery is necessary to address vision issues or resolve a medical issue, it may be considered medically necessary. In these cases, medical insurance may cover part or all of the surgery. Below are some of the common reasons eyelid surgery may be medically necessary.
Ptosis
Ptosis is a condition that is characterized by the drooping of the upper eyelid. It is often due to weakened upper eyelid muscles and can result in the eyelid partially or fully covering the pupil of your eye. When ptosis is this severe, it can impact your vision, and surgical intervention is often the only effective solution. Addressing the issue early on is the best way to reduce the impact on your daily life.
Impaired Vision
Excess skin on your upper eyelids can droop over your eye, obstructing your peripheral vision and making daily life difficult. Patients with impaired vision caused by eyelid drooping include reading, driving, and using a computer. They also may overcompensate by raising their eyelids. These factors can all lead to headaches and reduce your overall quality of life.
Eyelid Irritation
Excess skin or fat around your eyes can cause severe irritation and lead to redness and discomfort around your eyes. Eyelid irritation and its effects are common if your eyelid skin folds due to excess skin. Even worse, the symptoms cause patients to rub their eyes excessively, which exacerbates the issue. To avoid further damage to the eyes, patients with this condition typically need eyelid surgery to address the issue.
Tips for Demonstrating Medical Need for Eyelid Surgery
Obtaining medical coverage for eyelid surgery can be complex, but it is not impossible. Most importantly, it requires attention to detail and patience, as the process can take time. To ensure you get as much insurance coverage as possible for your eyelid surgery, consider the following information.
Document Your Vision Issues
Insurance companies are not eager to cover medical procedures if they do not have to. Because of this, it is critical to gather evidence to prove the medical need for eyelid surgery. Meeting your health insurance requirement for coverage is key. One of the key elements you need to demonstrate with evidence is medical necessity.
The first step in the process is documenting your vision issues. Vision complications to mention in the documentation can include reduced peripheral vision or evidence that the obstruction cannot be corrected with glasses or contact lenses. You can also note difficulty performing daily tasks such as driving, reading, or using electronic devices. To obtain this proof, you may need to request your eye doctor conduct visual tests to demonstrate and verify the issue.
Take Photos and Obtain Medical Records
Photos are also an incredibly helpful tool for showing the need for eyelid surgery. Take photos from the very beginning of the process because they can be used to show any progression over time. Take photos from several angles to fully highlight drooping skin or any other functional issues.
In addition to the photos, get copies of all of your medical records. Most importantly, these documents should include a diagnosis from your healthcare provider. If possible, have your medical provider provide a written statement with your diagnosis, past treatment, and the effect of the condition on your daily life. If they recommend eyelid surgery, have them include that in the letter. The documentation should clearly demonstrate why you need eyelid surgery for functional reasons related to your quality of life.
Treatment Plan
Many insurance providers recommend conservative treatment methods before surgery. Be sure to demonstrate that you received a diagnosis and completed a conservative treatment plan. Show evidence of this through medical records and photos. Be sure to document all of your symptoms and any issues you have during the treatment plan. This can be helpful in demonstrating the need for surgery to your medical insurer.
Navigating the Insurance Approval Process
After you have gathered the necessary evidence to demonstrate your need for eyelid surgery, you will need to get pre-approved. The pre-approval process for eyelid surgery can take time, so it is important to be patient. Focus on preparing your information in an organized and detail-oriented fashion.
Submit Your Pre-Authorization Request
Each medical insurance company is different. Look up and follow your specific insurer’s requirements for pre-authorization. Pre-authorization often includes all of the documentation listed above. Photos, medical records, and a letter from your doctor are all helpful. In some cases, you may need to schedule a consultation with an eyelid surgeon who has experience with the specific surgery you need. Once you have submitted your request, you may need to wait a couple of weeks for a response.
Response From Your Insurer
Your insurer will either approve or deny your request. If you are approved, you can move forward with the procedure. If not, you have the right to appeal the decision. In the case of an appeal, additional evidence or clarification can often support the need for the surgery. If your insurance company denies your claim after the appeal, you will need to plan how to finance your surgery. Luckily, there are several options available for financing cosmetic surgery, so you are not at the end of the road if your insurance denies coverage.
Funding Your Eyelid Surgery
If your medical insurer does not cover your eyelid surgery, there are several funding options to consider. Consider the following financing options.
Third-Party Financing
There are financing options through third-party companies. A popular option is CareCredit, which allows you to pay for the procedure in monthly payments to make the overall cost more manageable. The company will perform a credit check, and you will have to go through an approval process. Be sure to read the terms and conditions and consult with your financial advisor before moving forward. They have both short and long-term options. Verify the interest amount and the time frame of the loan at the start of the process.
Flexible Spending Accounts
Flexible spending accounts (FSAs) are accounts that allow employees to set aside pre-tax dollars for certain medical expenses. Traditionally, cosmetic procedures are not covered by FSAs. Still,, if your eyelid surgery is denied but is medically necessary you may be able to use the funds for it. Before you use the funds for your surgery, be sure to get it approved by your employer’s FSA administrator. You may need to provide documentation showing the specific issue, but if it is approved, it can be used for your eyelid surgery.
Medical Loans
If you do not qualify for financing and do not have an FSA, medical loans are available. You can get a medical loan from a bank or specialized lender. Medical loans are unsecured personal loans, which means that you do not need to provide collateral. As with any loan, verify the terms and conditions before taking them. This is especially important when it comes to the timeline of the loans and the interest rate.
Personal Savings
If you have personal savings available, it is always an option to pay cash for your treatment. This is a great way to avoid interest and additional debt if you do not want it. Verify all of the costs related to the procedure with your surgeon, including the procedure itself, the cost of the anesthesiologist, and any facility fees. This can provide you with a clear picture of what to expect in terms of the total cost of the eyelid surgery.
Schedule Your Consultation
If you are interested in eyelid surgery, contact Dr. Christopher Zoumalan’s team to schedule a consultation today!
