How to Get Insurance to Pay for Eyelid Surgery (Blepharoplasty): A Complete Guide

Blepharoplasty—more commonly known as eyelid surgery—is often seen as a cosmetic procedure reserved for those seeking a more youthful appearance. However, what many don’t realize is that eyelid surgery can also be medically necessary, and when it is, insurance might cover it.

If sagging eyelids are more than a cosmetic concern—if they’re actually impairing your vision—then you might not have to foot the bill yourself. But before you breathe a sigh of relief, know this: getting insurance to pay for eyelid surgery isn’t as simple as making a phone call. You’ll need documentation, testing, and persistence.

This blog post will guide you through every step of the process—from recognizing medical necessity to getting pre-authorization and navigating denials. Whether you’re just exploring the idea or ready to go under the knife, here’s everything you need to know.

1. Understanding Blepharoplasty: Cosmetic vs. Functional

Let’s start by clearing up a major misconception: not all blepharoplasties are cosmetic.

• Cosmetic blepharoplasty is performed purely for aesthetic reasons—to reduce puffiness, eliminate bags under the eyes, or tighten the skin for a more youthful look.

• Functional blepharoplasty, on the other hand, is performed to correct problems that interfere with your vision or eye health.

Insurance companies will only cover blepharoplasty if it is deemed medically necessary. So, the first step is determining whether your condition meets that criteria.

2. What Makes Eyelid Surgery “Medically Necessary”?

Most insurance companies define medical necessity by the impact your eyelids have on your vision or eye function. Some common conditions that may qualify include:

• Ptosis: A condition where the upper eyelid droops over the eye, often obscuring vision.

• Dermatochalasis: Excess skin on the eyelids that hangs down and impairs the visual field.

• Chronic eye irritation or difficulty wearing glasses/contact lenses due to excess eyelid skin.

If your sagging eyelids are blocking your peripheral vision, causing headaches, or leading to chronic discomfort, there’s a good chance you may qualify.

3. Start With an Eye Exam: Documenting the Problem

Before you can approach your insurance company, you’ll need hard evidence that your eyelid condition affects your vision. This usually starts with a visit to an ophthalmologist (eye doctor), who can perform several key tests:

Visual Field Test (Peripheral Vision Test)

This is the most critical piece of evidence. A visual field test measures how much your upper and side vision is being blocked. The goal is to determine whether the droopy eyelid is interfering with your daily life—like driving, reading, or navigating stairs.

Most insurers require that your upper visual field be reduced by at least 20–30% due to eyelid obstruction before considering coverage.

Photographic Evidence

Your provider may take pre-operative photographs showing:

• The eyelid margin in relation to the pupil

• The presence of excess skin

• How the condition looks with your eyes in a relaxed state

These photos help your insurer visualize the issue.

4. Try Conservative Treatments First

To show due diligence, some insurance providers require that non-surgical treatments have been attempted before surgery is approved. This might include:

• Artificial tears or ointments

• Lubricating eye drops for irritation

• Adjustments to glasses

Make sure any such treatments are documented in your medical record—even if they didn’t help.

5. Consult a Qualified Surgeon Who Accepts Insurance

Not all plastic surgeons accept insurance for eyelid surgery, and not all are experienced in the documentation process. Seek out:

• A board-certified plastic surgeon or oculoplastic surgeon

• Someone experienced in submitting functional blepharoplasty claims

• A provider whose office staff can help you with the insurance paperwork

During your consultation, ask whether they’ve had success getting similar procedures covered and if they will help with pre-authorization.

6. Get Pre-Authorization (Don’t Skip This!)

Here’s where many patients go wrong: assuming insurance will pay without a formal approval.

You’ll need to submit:

• Results from your visual field test

• Physician notes detailing the medical necessity

• Pre-operative photos

• A CPT code (usually 15823 for upper eyelid surgery when medically necessary)

Pre-authorization ensures that your insurance company acknowledges the necessity and agrees to coverage before the procedure. This can take days to weeks, depending on the insurer.

7. Writing the Medical Necessity Letter

Often, your surgeon or eye doctor will write a letter of medical necessity, but you can—and should—review it before submission. This letter should:

• Describe your symptoms (e.g., vision obstruction, fatigue, headaches)

• Include results from visual field tests and photographic documentation

• Explain why other treatments didn’t work

• Emphasize how surgery will improve your quality of life

The more clearly this letter connects your symptoms to your daily functioning, the better.

8. Understanding CPT and ICD-10 Codes

If you want to get technical—and you should—the codes used in your insurance claim matter.

• CPT Code 15823: Upper eyelid blepharoplasty with documentation of visual impairment (functional).

• ICD-10 Codes may include:

  • H02.403 – Unspecified ptosis of unspecified eyelid

  • H02.835 – Dermatochalasis of right upper eyelid

Using the correct codes ensures your procedure is billed as medically necessary—not cosmetic.

9. What to Do If Your Claim Is Denied

Even if you did everything right, your claim could be denied. But don’t give up—many initial denials are overturned on appeal.

Steps to Take:

• Request the reason for denial in writing.

• Review the insurer’s medical policy on blepharoplasty (often available on their website).

• Work with your doctor to submit an appeal that includes:

  • A revised letter of medical necessity

  • Additional or clarified visual field tests

  • Patient testimonials or journals about how your vision is impaired

Persistence pays. If necessary, appeal more than once. You also have the right to an external review if internal appeals fail.

10. How Much Does Insurance Usually Cover?

If your procedure is approved, insurance typically covers:

• The surgeon’s fee

• Facility/hospital costs

• Anesthesia

• Post-op follow-ups

However, you may still be responsible for deductibles, co-pays, or co-insurance, depending on your plan.

Also, note that lower eyelid surgery is rarely covered, as it is almost always considered cosmetic.

11. Final Tips for Success

• Keep a journal of your symptoms. Daily logs that describe headaches, eye fatigue, or difficulty seeing can be powerful support.

• Stay organized: Keep all letters, tests, and communication in one place.

• Communicate with your provider’s billing department. They’re your best ally.

• Be patient but persistent. Insurance approvals can be slow, but if your need is real and documented, you have a strong case.