A detailed explanation of how a surgeon determines if insurance covers eyelid surgery.

Possibly the most common question prospective patients have is whether or not insurance covers eyelid surgery. There are several factors that need to be considered when answering this question, especially regarding surgery that corrects drooping eyelids, or ptosis repair. While the answer to this question has many components, it is rather simple to break it down.

At the time of consultation, our Oculofacial surgeon Damon B. Chandler, M.D. will ask to take a several photos of your eyes, one of which is taken straight on, or in primary position. These photos will be the foundation of your surgical experience. Not only will this be a basis for comparison from start to finish, but within these photos lies three of the four checkpoints necessary in establishing if insurance covers eyelid surgery.

 

cosmetic versus functional ptosis

Pictured above are an eye without ptosis (left), ptosis that is considered cosmetic in nature (center), and functional ptosis, or ptosis covered by insurance (right).

 

 

1.  Is the distance from the upper eyelid to the lower eyelid in a normal range?

The palpebrae fissure height, or PF, refers to the distance between the upper and lower eyelid margins with the pupil acting as the axis. Normal measurement is typically 9 to 12 mm. By comparing the photos above, it is clear the PF differentiates from an eyelid without ptosis, to a cosmetic ptosis repair, and even more drastically to a functional ptosis repair.

 

2. Is the distance from upper eyelid to the middle of the eyeball in a normal range?

The marginal reflex distance, or MRD, measures the distance between the middle of the eyeball and the upper eyelid. Oftentimes, the degree of ptosis is better determined by analyzing MRD versus PF, as it eliminates the factor of any possible lower lid malfunction. MRD is typically 4 to 5 mm. Referring back to the photos above, the MRD is so abnormal in the case of cosmetic ptosis that the upper lid appears to be resting on the pupil. Exploring further, the functional MRD could be considered almost non-existent.

 

3. Is the camera flash visibly reflected the pupil of your eye?

Once PF and MRD are assessed, a final indication of ptosis severity, and arguably the most telling aspect of deciding if insurance covers eyelid surgery, is the camera flash. Oftentimes, this component will be the final step in the first leg of determining if drooping eyelid surgery is covered by insurance.

Using the photo above as a reference, it is clear that the flash from the camera can be seen in both the eye without a droopy eyelid and the cosmetic ptosis photo. The flash, however, is not visible in the functional ptosis photo due to the lid drooping.

 

These are three simple indicators of whether or not insurance covers eyelid surgery. If the answer is “yes” to any of these questions, ptosis repair would generally be considered cosmetic in nature. If ptosis is severe enough to answer “no” to all three, a more detailed test will be recommended. In our next post we will explore this test, the Humphrey Visual Field test, as well as the financials surrounding cosmetic and functional ptosis repair.

 

For a complete guide to cosmetic eye surgery, and for a FREE consultation with Dr. Chandler, download our eBook, “How Do I Know if Cosmetic Surgery is Right for Me?”