Does Medicare Cover Eyelid Surgery?
Blepharoplasty, commonly referred to as eyelid surgery, is the removal of excess skin from your eyelids. Your ophthalmologist may suggest this procedure if you have upper eyelids that droop, bags under your eyes, or excess skin in your upper or lower eyelids. Because surgeons perform blepharoplasty for both cosmetic and medical purposes, Medicare requires prior authorization. As with most health insurance plans, Medicare restricts coverage to medically necessary services.
Why you may need eyelid surgery
According to the Centers for Medicare & Medicaid Services (CMS), “the goal of functional restorative surgery is to restore significant function to a structure that has been altered by trauma, infection, inflammation, degeneration (e.g., from aging), neoplasia or development errors.”
Reconstructive surgery may correct visual impairment, repair defects, treat conditions related to thyroid disease or nerve palsy, or alleviate pain endured from conditions causing uncontrollable eyelid movements. Medicare deems the procedure cosmetic if no signs or symptoms of a functional abnormality are present.
Medicare coverage for outpatient surgery
Surgeons typically perform blepharoplasty in an outpatient setting. Medicare Part B covers outpatient surgical services and supplies. You are responsible for the Part B deductible and 20% of the Medicare-approved charges. Hospital outpatient departments may also bill a copayment for facility use. If you have a Medigap plan, check your plan for coverage of coinsurance and any copayments.
Ambulatory surgical centers tend to be less expensive than hospital outpatient departments. For example, according to the Medicare procedure-price-lookup tool, the national average out-of-pocket cost for upper eyelid blepharoplasty (code 15822) is around $258 in an ambulatory surgical center versus $430 in a hospital outpatient department. Charges vary by location, so check with the facility where your doctor plans to schedule the surgery.
If your doctor prescribes post-surgical eye drops or ointments after your surgery, refer to your Part D formulary for prescription drug coverage. Medicare Advantage plan members may have Part D included in their benefits. Medicare Advantage plans usually cover prescription drugs, but some plans may include an allowance for nonprescription medication and over-the-counter products like ice packs, aspirin, Advil or Aleve that may help you manage postoperative pain.
Other elective procedures
Blepharoplasty is one of several services that may be elective or medical. In addition to eyelid surgery, Medicare requires prior authorization for botulinum toxin injections or Botox (to relax muscles), panniculectomy (to remove excess abdominal skin or tissue), rhinoplasty (to change the shape of a nose) and vein ablation (to close off varicose veins).
The Social Security Act excludes Medicare coverage for procedures performed exclusively to enhance appearance without a functional benefit. Medicare will deny the claim for services with no medical justification. According to the American Society of Plastic Surgeons, the average cost of aesthetic eyelid surgery is $4,120 plus the cost of anesthesia, the operating room and other related fees.
Resources for more information
Credible sites offering informative articles about blepharoplasty include the American Academy of Ophthalmology (AAO), the Journal of the American Medical Association (JAMA) and MedlinePlus/National Library of Medicine. Your research findings can help you prepare a list of questions to discuss with your doctor during your consultation.