How Does Medicare Qualify for Blepharoplasty Eyelid Surgery?

Blepharoplasty is a surgical procedure performed to restructure the eyelid. The effects of aging cause the eyelids to stretch and supporting muscles to weaken, producing droopy upper eyelids and sagging lower eyelids. 

When it comes to cosmetic surgery procedures performed in the United States, surgery done on the upper or lower eyelids ranks in the top 5 for both men and women. 

Some people opt for plastic surgery or surgical intervention to enhance their appearance. If the condition is extreme enough where the excess skin, sagging muscles and fat reduces your peripheral vision, your doctor may recommend blepharoplasty for medical reasons.

Will Medicare Pay for Blepharoplasty?

Medicare coverage applies to medically necessary procedures including reconstructive surgery to correct or restore function to a part of the body. Top reasons to perform blepharoplasty surgery of the upper eyelid include:

• Reconstruct deformity
• Improve function
• Correct visual impairment
• Enhance appearance

However, if you undergo blepharoplasty for cosmetic anti-aging purposes, you will be responsible for the total cost. The American Society of Plastic Surgeons found that the 2020 average cost of eyelid surgery was $4,120. This estimate is only for the plastic surgeon’s fee, not anesthesia, facility charges, or related expenses.  

Medicare will pay for blepharoplasty when certain guidelines are met. The procedure is considered medically necessary, for example, if you are showing physical signs of excessive upper eyelid skin or the results of a visual field test conducted by an ophthalmologist demonstrate a minimum of 30 percent of visual field obstruction.

Medically necessary surgery, such as cataract removal, is covered under Part A or Part B, depending on whether or not the medical procedure requires hospital admittance. Blepharoplasty is usually done on an outpatient basis, but if hospitalization is needed, the cost of hospital services falls under Part A. While you are in the hospital, the cost of your doctor’s services falls under Part B.

Blepharoplasty Part A Medicare Benefits

Part A is hospital insurance, which covers a semi-private room, general nursing and medication. Your out-of-pocket cost as an inpatient includes:

• Part A deductible: $1,484 in 2021
• Coinsurance per day if you stay longer than 60 days

Medicare does not cover a private room, private nursing, or personal care products. The cost of these services and items would be at your own expense. If you choose to cover these expenses yourself, you can find out the costs in advance. A new requirement in 2021 is that hospitals must publicly disclose their standard charges for all items and services. 

Blepharoplasty Part B Medicare Benefits

Part B is medical insurance, which includes your doctor’s services and outpatient care. Your out-of-pocket costs for outpatient procedures, diagnostic services and treatment include:

• Part B deductible: $203 in 2021
• 20% coinsurance
• Copayment charged by hospital outpatient facility

The Medicare procedure-price-lookup tool shows the following national averages for out-of-pocket costs based on Original Medicare 2021 payments:

• Ambulatory surgical center: $284
• Hospital outpatient department: $454

Blepharoplasty Eyelid Surgery Resources

Medicare Advantage benefits may extend beyond Original Medicare coverage and may have different deductibles, coinsurance and copayments for this procedure. Talk to your plan directly for specific information regarding blepharoplasty cost and Medicare requirements for blepharoplasty.