Functional vs. Cosmetic
One of the most common questions we encounter is "Will insurance cover my procedure?" The answer is maybe.
An upper blepharoplasty, the removal of excess skin and fat from the upper eyelids, is often covered if:
- The excess skin causes the patient a problem.
- The skin hangs over the eyelid and interferes with vision.
- Photographs show the excess skin is present.
Most insurers require (and will pay for) patients to undergo the tests needed to answer these questions.
We are required to submit all this data to the insurer.
The insurer makes the determination if the procedure will be covered or if it is cosmetic.
How the insurer decides this varies from one company to the next. In general they look at:
If the records show these 3 things, most insurers will approve the surgery.
- The medical record to show there is a documented problem
- The visual field tests for a significant obstruction which resolves when the excess skin is taped out of the way
- The photographs to determine if the excess skin jives with the visual fields and patient complaints
How long is the approval process?
We deal with all the local insurers and the answer to this is, it depends.
Some insurers will return a determination within days.
Of the national providers we deal with, we have found that some insurers, such as Blue Cross of Illinois and Blue Cross of Rhode Island,
will rarely provide an authorization. People with these plans are nearly always cosmetic.
Medicare instructs the surgeon to do the tests and if the surgeon thinks you meet the Medicare published guidelines,
go ahead and do the surgery. Medicare will decide, after it is done, if they will pay for the surgery.
We will let you know based on our experience how likely it is that Medicare will pay for your surgery.
Medicare patients who are well within the guidleines have no fear, the surgery will be covered.
But those who are borderline will need to sign an ABN (Advance Beneficiary Notice) which states Medicare may not pay for the procedure -
it might be cosmetic. This ABN is a Medicare requirement.
Even its name sounds like something from the government!
Patients with Medicare Managed Care Plans go through the pre-authorization process just like non-Medicare patients.
We know before the surgery what is covered and what is not.