Does Medicare Cover Eyelid Surgery?

Eyelid surgery is often considered a cosmetic procedure when it is requested by patients as a way to tighten the eyelids and surrounding skin to achieve a more youthful appearance. In some cases, eyelid surgery is needed to correct eye health conditions that interfere with the field of vision.

Does Medicare Cover Eyelid Surgery?

Eyelid surgery may be covered under limited circumstances through Original Medicare (Medicare Part A and Part B) and by Medicare Advantage (Medicare Part C) plans if the surgery is deemed medically necessary. 

When eyelid surgery is specifically for cosmetic purposes, it is not covered by Original Medicare benefits. That means hooded eye surgery costs and those for other cosmetic procedures will be the responsibility of the patient.

For eyelid surgery to be approved through Medicare, the recipient must be able to prove that the procedure will benefit their overall health and is not needed for cosmetic reasons. Some examples of non-cosmetic eyelid surgery include:

• Blepharoplasty for hooded eyes: Severe eyelid drooping that causes the skin of the eyelids to cover a significant portion of the eye may be covered by Medicare if deemed necessary by a doctor. 
  
  
• Eyelid cancer surgery: Eyelid cancer surgery removes cancerous cells from the external skin of the eyelids with specialized techniques to help preserve healthy surrounding tissue. Medicare recipients should consult with Medicare to determine if eyelid cancer surgery is a covered procedure based on their specific plans.
  
  
• Ectropion and entropion surgery: Ectropion and entropion surgery are procedures to correct eyelids that turn inward or outward. In severe cases, this condition can cause the eyelids not to shut completely. This surgery may be considered medically necessary by a physician and Medicare. 

Criteria for Eyelid Surgery Covered by Medicare

Medicare requires that eyelid surgery procedures meet specific criteria to be covered byMedicare Part B. This criteria includes:

• The excess eyelid skin is diagnosed by physical examination.
  
  
• There must be proof of at least 30% or 12 degrees of obstruction of the visual field caused by the underlying medical condition. This must be determined via visual field testing performed by a Medicare-approved ophthalmologist. 
  
  
• Medicare-approved physicians must state the surgery is medically necessary and/or recommend the procedure. 
  
  
• Photographs and documentation of visual problems must be provided to Medicare.

Necessary Medical Eyelid Surgery That Also Improves Appearance

In some cases, procedures to correct severely drooping eyelids or other medical issues may also unintentionally improve a recipient's appearance.

Approved coverage shouldn't be impacted if a patient achieves the dual result of healthier eyelids and an improved appearance because the covered procedure was intended to treat the medical issue. 

Blepharoplasty (Hooded Eye Surgery) Procedure Overview

Blepharoplasty to correct drooping eyelids is typically performed on an outpatient basis. The eyes are numbed prior to the procedure to ensure the patient doesn't experience pain or discomfort. During the procedure, the surgeon makes small incisions along the upper or lower eyelid folds. In some cases, both the upper and lower lids are treated.

Following the incision, excess skin is removed, along with excess fat or muscle when applicable. In some procedures, a surgeon may actually redistribute the fat or muscle throughout the affected area. After removal of excess tissue and/or redistribution, the incisions are closed and the surgery is complete. 

Aftercare

Following aftercare instructions after an eyelid surgery procedure is essential to promote proper healing. While specific aftercare instructions may vary depending on the procedure, here are some common recommendations:. 

• Apply ice packs to the eyes for up to 10 minutes a day or as directed by a physician.
• Avoid wearing contact lenses for up to two weeks following the surgery.
• Wear sunglasses when outdoors to protect healing eyes from the elements. 
• Use provided prescription drops or ointments as directed by a physician. 
• Sleep with the head elevated if possible.

Potential Temporary Side Effects Following Surgery

It's common for patients to experience a few transient side effects following surgery that should gradually subside. Swelling and bruising around the eyes and watering eyes can be uncomfortable, but they are usually temporary. Patients should contact their physicians if they experience any of the following:

• Bleeding
• Shortness of breath
• Unexplained new eye pain that's severe in nature
• Chest pain
• Unusual heart rate

What Is the Average Cost for Eyelid Surgery?

Per the American Society of Plastic Surgeons, the average cost for blepharoplasty to correct drooping eyelids is $4,120.

Costs for entropion/ectropion surgery can range between $500 and $2,000, and eyelid cancer surgery varies in price between approximately $2,000 and $5,000. 

How Do Physicians Qualify Patients for Medically Necessary Eyelid Surgery?

Along the same lines as Medicare, most insurance companies only cover lower and upper eyelid surgical costs that are medically necessary and performed to correct functional problems or to reconstruct the eye area for non-cosmetic purposes.

Doctors must perform tests to determine that the field of vision is affected by the condition, and they must document issues that can potentially qualify patients for surgery. All documentation must be provided to the patient's insurance company.

Eye conditions and symptoms that may help qualify a patient for covered eyelid surgery include:

• Blepharochalasis (swelling of the eyelid)
• Conjunctival inflammation
• Inflamed corneas
• Orbital fat protrusions
• Difficulty in closing one or both eyes
• Bags under the eyes
• Enlarged muscles around the eyes