Why Eyelid Ptosis Surgery Covered by Insurance Does Not Include Cosmetic Eyelid Surgery

Why Eyelid Ptosis Surgery Covered by Insurance Does Not Include Cosmetic Eyelid Surgery


Thank you for your question. You submitted your question with two photos. And you stated in your question that you had
ptosis repair due to a weakened muscle and that you are satisfied with the repair. However, there is a certain amount of skin
that is present after the ptosis repair. And that your surgeon stated that you would
have to pay to have the skin removed. And you’re asking if should it have been
done as part of the surgery. Who is right? Well, I can share with you what I think is
the general opinion of doctors in this oculoplastic community assuming that you did have this
surgery by an oculoplastic surgeon. And I’ll explain what I think is the thought
process behind what your doctor is stating without knowing much of the detail. And I can understand your confusion. A little bit of background, I’m a Board-certified
cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long
Island for over 20 years. Dealing with eyelid ptosis is a significant
part of my practice as well as cosmetic surgery. In my practice, I don’t accept any insurance
and I do see patients who come for ptosis surgery who make the choice to come to a specialist
like myself to have the cosmetic elements of their eyelid surgery addressed in addition
to the function. And this is where I think it has to be clarified. I think that one of the things I find when
patients come to me for examination regarding eyelid ptosis that there is this unspoken
assumption from really generations of practice where people who had a degree of either dermatochalasis
which is extra skin over the eyes or ptosis, the eyelid drooping that was affecting the
visual field would undergo surgery through their insurance because it was a functional
limitation. Well unfortunately, there has been a tradition
also of abuse of that particular issue and a lot of times people try to get cosmetic
surgery covered by insurance. And of course, insurance companies don’t want
to do that or neither do any third party. And that of course is a challenging point. I think that a lot of times, when people want
to have a procedure covered by insurance, the surgeon is going to be limited to doing
only what is covered by insurance. And so it becomes also actually an issue when
it comes to the hospital or surgery center that they’re working in because the time
involved in doing the other procedures that are more cosmetically oriented costs in terms
of anesthesia, time and facility and other factors. Now there is always going to be a certain
amount of controversy with that type of statement. But when I see my patients and I say to them,
well if your goal is to only lift the eyelid, the strict definition of improvement is essentially
lifting the eye and improving vision. Insurance companies don’t care whether it
looks good or not. And so I think that this is something that
could have been discussed with your doctor prior to the surgery. I think that the challenge here is also whether
or not your procedure, in the context of how it would be performed, there are going to
be costs and I think that’s what is somewhat confusing to patients who get procedures covered
by insurance and if they don’t like the aesthetic outcome, then they want to get the cosmetic
procedure but they are faced with dealing with paying for a cosmetic procedure, one
of the many reasons why I stopped taking insurance many years ago. I think that if you like the doctor that did
your surgery and you feel comfortable with that doctor, I think that you should be able
to come to terms which can be balanced for both of you. Understanding that there are certain costs
in doing surgery and that doctor’s time etc. have to be recognized and also about what
was your discussion preoperatively. If there was a discussion about the cosmetic
aspects of your procedure, I think it’s very important to have a lot of just clear
full disclosure of what is covered and what is not covered. And so I simplify it by simply stating that
nothing is covered when you come to a cosmetic surgeon who does not accept insurance. Then what I’m essentially doing in my practice
is telling my patients that by having my own facilities, by having my own setup, that any
type of enhancement, I will essentially factor in into the cost of doing the procedure. And therefore, my patients have a more sense
of security as to what they will get by addressing all the issues both functional and cosmetic. The tricky part happens when people get procedures
under insurance and then they want cosmetic things covered. And so again, it’s not exactly a black and
white situation. I think defining the distinction between functional
versus cosmetic is very important and having this discussion with your doctor will hopefully
lead to some kind of solution. Otherwise, I think that if you were to go
to any doctor to have the upper eyelid addressed, that would be a cosmetic blepharoplasty and
that may itself be the basis to understand that part of your issue is ultimately a cosmetic
procedure. So I hope that was helpful, I wish you the
best of luck and thank you for your question.

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