A Cross-Sectional Analysis of American Insurance Coverage of Upper and Lower Lid Blepharoplasty

Goals/Purpose: Dermatochalasis, or “baggy eyelids,” is a common condition characterized by redundant skin around the eye that occurs naturally with age. In severe cases, it can cause obstruction of peripheral visual fields and impairment of daily activities. These effects can be addressed with a blepharoplasty, which may be considered a cosmetic procedure by American health insurers. The authors assessed insurance coverage of all indications of blepharoplasty and their medical necessity criteria.

Methods/Technique: s: A cross-sectional analysis was conducted of 70 insurance policies for blepharoplasty. The insurance companies were selected based on their state enrollment and market share. A web-based search and telephone interviews were utilized to identify the policies. Medically necessary criteria were then extracted from the publicly available policies.

Results/Complications: Of the 70 insurance policies assessed, 67 (96%) provide coverage of blepharoplasty. There were seven indications for coverage, the most common being dermatochalasis causing functional visual impairment (n = 56, 80%), prosthesis difficulties in an anophthalmic socket (n = 44, 63%), and congenital ptosis (n = 38, 54%). Of the 56 companies that indicated coverage for dermatochalasis, 53 (95%) required visual field loss testing to qualify for coverage. Significantly more companies required a 30% loss in superior visual field for coverage versus the literature recommended amount of 24% loss (n = 14 versus n = 3, 26% versus 6%, p = 0.0067).

Conclusion: There is a great discrepancy in insurance policy criteria for coverage of blepharoplasty, especially regarding requirements for visual field testing. Unfortunately, this disparity does not reflect the current literature as to whom may gain significant functional benefit from blepharoplasty.