Does Medicare Cover Blepharoplasty and a Brow Lift?

Blepharoplasty and brow lift procedures involve surgical interventions around the eyes and forehead. Blepharoplasty, commonly known as eyelid surgery, addresses issues like droopy eyelids by removing excess skin, muscle, or fat. A brow lift, on the other hand, elevates the eyebrows to correct sagging or furrowing in the forehead region. While these procedures can offer aesthetic enhancements, Medicare coverage depends on whether they are considered medically necessary rather than solely cosmetic.

Understanding Medicare’s Coverage Approach

Medicare’s fundamental principle for covering surgical procedures hinges on the concept of “medical necessity.” Medically necessary services are defined as healthcare services or supplies that are needed to diagnose or treat an illness, injury, condition, disease, or its symptoms, and that meet accepted standards of medicine. The Centers for Medicare & Medicaid Services (CMS) provides detailed criteria to determine what constitutes a medically necessary service. Services must be proper and needed for the diagnosis or treatment of a medical condition, and they must adhere to good medical practice standards.

Medicare generally does not cover cosmetic surgery, which is primarily performed to improve appearance without a functional benefit. This policy applies unless the surgery is required due to an accidental injury or to improve the function of a malformed body part.

Specific Criteria for Coverage

For blepharoplasty, Medicare may consider coverage when the procedure is medically necessary to correct impaired vision or other functional issues. This often involves excess skin and loss of elasticity that causes eye inflammation, impairs vision, or makes wearing glasses difficult. Other medically necessary reasons include chronic inflammation from allergies or thyroid eye disease, uncontrollable eye spasms unresponsive to other treatments, difficulty fitting a prosthesis in an empty eye socket, or repair of damage from injury or developmental issues.

If a blepharoplasty is performed for both cosmetic and medical reasons, Medicare can only cover the portion deemed medically necessary.

In contrast, a brow lift is almost exclusively considered cosmetic by Medicare, meaning it is not covered when performed solely to enhance appearance. Medical necessity for a brow lift is rarely met, as it typically does not address a functional impairment in the same direct way that blepharoplasty might. However, in very limited circumstances, a brow lift might be considered medically necessary if it is required to achieve a satisfactory functional repair in conjunction with or as an alternative to upper eyelid blepharoplasty. Without clear documentation of a functional impairment directly linked to the brow position, Medicare will not provide coverage.

Navigating the Approval Process

Prior authorization is required for blepharoplasty before Medicare will cover the service. This process ensures that the requested treatment meets Medicare’s guidelines for medical necessity. Your healthcare provider or the hospital’s pre-services department is typically responsible for submitting this request along with comprehensive documentation.

The required documentation is extensive and must clearly support the claim of medical necessity. This includes detailed physician’s notes, medical records that clarify the functional difficulty, and specific results from diagnostic tests like visual field examinations. Additionally, clear color photographs showing the physical effects of the condition are essential. This thorough package of information helps Medicare or your Medicare Advantage plan determine if the procedure qualifies for coverage.

Once submitted, the prior authorization request is reviewed by Medicare, a process that can take several days to weeks, with some reviews requiring around 14 days. If your healthcare provider believes Medicare may not cover a service, even if medically necessary, they might ask you to sign an Advance Beneficiary Notice of Noncoverage (ABN). This form acknowledges that you may be responsible for the costs if Medicare denies coverage.

Financial Implications of Non-Coverage

If Medicare determines that a blepharoplasty or brow lift is primarily cosmetic or does not meet the strict medical necessity criteria, the procedure will not be covered. In such cases, you will be responsible for 100% of the costs. This means all expenses, including the surgeon’s fees, anesthesia, and facility charges, become out-of-pocket costs.

Even if a procedure is deemed medically necessary and covered by Medicare, you will still incur out-of-pocket expenses. For Original Medicare Part B, which covers outpatient services like blepharoplasty, you are responsible for the annual deductible, which is $257 in 2025. After meeting the deductible, Medicare typically covers 80% of the Medicare-approved amount, leaving you to pay the remaining 20% coinsurance. For procedures not covered, patients may explore private payment options, financing plans offered by surgical centers, or personal loans.

Should Medicare deny coverage for a procedure, beneficiaries have the right to appeal the decision. The appeals process in Original Medicare typically involves five levels:

• Redetermination by a Medicare Administrative Contractor
• Reconsideration by a Qualified Independent Contractor
• A hearing before an Administrative Law Judge
• Review by the Medicare Appeals Council
• Judicial review in a U.S. District Court

You can initiate an appeal by following the instructions on your Medicare Summary Notice (MSN) or the denial letter, typically within 120 days for Original Medicare. While you can appeal on your own, assistance is available from State Health Insurance Assistance Programs (SHIPs) or by appointing a representative.