Blepharoplasty is a surgery which repairs droopy eyelids. The procedure may be performed for cosmetic, functional, or reconstructive reasons. The American Society of Plastic Surgeons notes that insurance companies will only cover the surgery when it is classified for reconstructive or functional problems such as ptosis (drooping due to muscle weakness or nerve damage), blepharochalasis (eyelid swelling), dermatochalasis (excess skin), herniated orbital fat (excess fat), floppy eyelid syndrome and visual field obstruction.
Instructions
Insurance payments for blepharoplasty
1. Make an appointment to see an ophthalmologist or optometrist. These doctors can determine if you might be a candidate for blepharoplasty and can refer you to an appropriate surgeon.
2. Document the need for surgery. Your doctor must indicate that blepharoplasty is medically necessary, documenting any of the following issues:
• Blepharochalasis
• Conjunctival (membrane the covers the white part of the eye) inflammation
• Dermatochalasis
• Edema (swelling)
• Eyelid and/or eyebrow ptosis
• Hypertrophy (enlargement) of the orbicularis oculi (muscles that work the eyelids)
• Keratitis (cornea inflammation)
• Lagophthalmos (poor eyelid closure)
• Malar festoons (bags)
• Protrusion of orbital fat
• Visual field defects
3. See a surgeon. He should take photographs to document the condition for which a correction is needed. Sometimes an insurance company will ask to see the photos and patients would need to sign a release form.
4. Get all pre-operative diagnostic tests suggested by your doctors. These may include:
• Bleeding and clotting studies
• Cardiac evaluation
• CBC (complete blood count) / SMA-7 (a blood metabolic panel)
• Schirmer's test (dry eye test)
5. Make sure you sign a release form whenever you see a doctor or have any tests. Your medical records can then be sent to other doctors and to your insurance company.
6. Make sure your doctor uses the appropriate diagnostic codes to differentiate reconstructive from cosmetic surgery when billing your insurance company. In addition to using these specific codes, your surgeon must include documentation to back up the diagnosis.
