Eyelid Surgery and Medicare

There are many reasons people consider eyelid surgery, both cosmetic and medical. This is a commonly requested procedure for those enrolled in Medicare, for as we age our skin loses its elasticity and where this occurs around the eyes it can cause vision issues.

Whatever your reasons for seeking an eyelid procedure, you may wonder whether Medicare eyelid surgery is appropriate or available to you.

Conditions that May Require Eye Lid Surgery

For many people a sagging or drooping eyelid can obstruct the view or result in hanging of the eyelash in the way of their view. A heavy eyelid can also cause fatigue if you need to raise the eyebrows to improve your vision.

In cases where vision is obstructed (the proper term is functionally disturbing), Medicare and most insurance companies will cover the cost of eyelid surgery.

There is a specific measurement requirement before Medicare will approve the procedure. See your Doctor or Optometrist for the specifics. We believe the allowance is 12 degrees of the upper field of vision being blocked, or if the eyelid hangs down within 2.5 millimeters of the mid-pupil.

Blepharoplasty and Medicare

The procedure (called upper lid blepharoplasty) removes extra skin, muscles, and fat tissues from the upper lid of your eye by giving you local anesthesia. This eliminates loose overhanging eyelid tissue.

Some clinics are set up for day surgery procedure, but it may need to be done at your local hospital if a specialist is not nearby. Stitches close the cut and are removed in about 7 days. Swelling and brusing is common for up to two weeks.

Entropion And Ectropion Eye Lid Surgery

If the upper lids are sagging, there is a chance the lower lids can also sag. When this happens one of two problems will manifest. The lower eyelid will either turn inward making the lashes touch your eye, or fall outward away from the eye, leaving an uncomfortable gap.

Both of these problems are considered functional problems and are covered by Medicare and most Medicare supplement companies.

Eyelid Surgery for Ptosis

Another condition which is separate from sagging eyelid skin is ptosis. The muscle used to raise your eyelid sometimes loses its hold on the lid, letting it fall. Repairing this condition requires tightening the eyelid muscle deep in the upper lid. In some cases this procedure is combined with blepharoplasty if both conditions are present.

Eye Lid Surgery and the Medicare NEMB

Medicare will not provide coverage for all your healthcare requirements. Many exclusions apply and these will have to be paid out of a patient’s own pocket.

Depending on the circumstances, your eyelid surgery or eyebrow surgery may or may not qualify as a surgical necessity. Often any surgical work will fall into the cosmetic surgery category if your lifestyle isn’t severely impaired by your condition, whatever it may be.

Claims cannot be filed with Medicare for any service that is not covered by Medicare benefits. You will be asked to sign a Notice of Exclusion from Medicare Benefits (NEMB) and having reviewed your situation, you will be given an estimate of costs that must be paid prior to your procedure.

What to Do Next...

If you feel you may be a candidate for Medicare eye lid surgery, talk your Doctor about the specifics of your condition to find out if you qualify for supplemental health insurance coverage.