Is Ptosis Surgery Covered by Insurance?

In general, insurance companies do not cover ptosis surgery. However, if your ptosis is severe enough that your eyelids cause a significant visual obstruction and the condition affects your daily living activities, insurance coverage may be offered. Specifically, if the drooping upper eyelids block enough of your vision to significantly affect your life, then ptosis surgery could be considered medically necessary and may then be covered by insurance.

Insurance companies may use certain criteria to determine if ptosis surgery is medically necessary. They typically need the following information:

Notes from your Physician. These notes must clearly document the position of the eyelids and the patient’s complaint about the ptosis interfering with certain daily activities (driving, reading, etc.). 

Pictures of the Eyes and Eyelids. Clear frontal and side photos are required to clearly show the eyelids or extra eyelid skin obstructing the line of site, specifically falling within less than 2 millimeters of the center of the pupil. 

Visual Field Test. This non-invasive test is used to evaluate peripheral vision and is usually performed at an eye doctor’s office. The visual field is tested both with the eyelids in their natural position and with them held up (usually with special tape). The difference between the taped and un-taped visual field can show how much vision is impacted and determine whether or not the insurance will cover ptosis surgery. 

Occasionally there are other indications that insurance companies will accept to cover ptosis surgery. Reconstruction after thyroid eye disease, congenital ptosis and chronic dermatitis due to skin rubbing on the eyelashes are a few of these indications.

If you are considering ptosis surgery and wondering if your insurance will pay for the procedure, it’s generally easy to find out. Just ask your insurance company whether your procedure is included in your plan—that is, whether they’ll cover it and if so what percentage they’ll cover. 

Always check with your health insurer before you make any assumptions about coverage. In many cases it is hard to determine what is considered medically necessary or simply elective. 

If you are interested in ptosis surgery and would like to discuss your options with Dr. Perman, contact us in Fairfax to schedule a consultation.