But if you're asking about their possible coverage for cosmetic eyelid surgery-- well, is it possible that you've been living on another planet?
Yes, we know what you heard from your best friend who underwent "free" eyelid surgery fifteen years ago during the Golden Age of Medicine. And yes, we know that your insurance policy probably contains a paragraph of fine print that mentions something about coverage for eyelid surgery undertaken to correct "significant changes that impact on vision or the health of the eyes".
Well, get ready to face the music. Unless your cousin happens to be the Utilization Review Coordinator for your insurance carrier, your HMO, PPO, Medicare, or any other insurance company is not going to pay for cosmetic blepharoplasty. By its very definition, "cosmetic" surgery implies surgery undertaken with the primary goal of improving appearance, and surgery undertaken for such a reason is excluded from coverage.
Here's where the confusion may arise. Some patients believe that if they complain to their doctors that their baggy eyelids are "heavy" or make them "feel tired" and sometimes can "be felt" sitting on their eyelashes or that their lids are "interfering with the vision" that the medical insurance companies are happy to cut them a check for their eyelid surgeon's going price.
Not so anymore. In today's era of "managed care", your insurance policy's vague provision stating something to the effect that "significant changes that impact on vision or the health of the eyes" will be considered for coverage is referring to nothing short of the sort of far advanced changes that are found in eighty year old patients.
The upper eyelid skin must be extremely baggy and all but obliterating the eyelashes and covering the top half of the pupil. "Symptoms" carry little or no weight at all and even abnormal tests showing diminished peripheral vision are starting to be looked at with a jaundiced eye. Why? Because it doesn't take a Rhodes Scholar to figure out that if you can't see the flashing lights during your peripheral vision test your surgery is more likely to be covered.
The most convincing evidence of a substantial problem is best captured on close-up photography that must clearly show the level of severity described above. But even if you are eighty years old and your eyelids really are blocking your vision, there are still more limitations for you to consider.
Insurance companies will allow for only the minimum amount of surgery it takes to eliminate the vision problem (a "functional blepharoplasty"), which is not the same as a complete cosmetic blepharoplasty.
Removal of bulging fat, excess orbicularis muscle, and restoration of the upper eyelid crease are not improvements your insurance carrier is anxious to fund. Thus, even if you are one of the few people who is able to convince your insurance company that you really do NEED to have eyelid surgery, you should realize that you will only be receiving approval for the most basic sort of functional surgery that is unlikely to do much for your looks.
Lower eyelid blepharoplasty, by the way, is never covered since bulging lower eyelid skin and fat have no way of interfering with your vision unless you stand on your head.
As if the all of above obstacles weren't enough, you should also consider this. Most experienced cosmetic eyelid surgeons are not overly interested in providing quality cosmetic surgical services to patients who pay less than their regular fees.
Thus, even if your insurance company does "allow" for some minimal "functional" surgery and then agrees to pay the meager pittance that their usual-and-customary fee schedule deems to be adequate, don't expect a quality cosmetic surgeon to be willing to accept that amount as full payment. There is, quite simply, no profit in providing cosmetic services under such an arrangement while all of the business overhead and risks to the surgeon remain exactly the same.
Perhaps you will be able to find a cataract surgeon whose practice is slow or a beginning dermatologist who has run out of acne patients. But quality surgery by the very expert you most desire? Don't count on it.
By the way, there are some conditions affecting the eyelids that truly are "problems" and not cosmetic in nature, such as torn muscles and stretched tendons that create true eyelid malposition, interference with vision, and a threat to the integrity of the eye surface. These conditions (ptosis, ectropion, entropion, eyelid retraction, etc.) should not be confused with dermatochalasis (the fancy word for baggy eyelids). True functional conditions of the eyelids are indeed insurance-related expenses, although any correction is usually provided by general ophthalmologists rather than cosmetic eyelid surgeons.
