No Insurance Authorization for Eyelid Implant

[Mimispree]

I was scheduled to get an eyelid weight implant on Monday, but I just got a call saying the insurance will not authorize it because it's considered cosmetic surgery.  Wow.  I guess because the doctor wanted to put a stitch in my lower eyelid to tighten it up, that made it cosmetic, but my face (lower eyelid) is really drooping and without the tightening my eye still won't be able to close even with the weight.

This is disappointing news because I'm wearing an eye-patch basically 24/7 in order to close my eye. 

Any advice?

[NYLady]

I would give your doctors office a call to see if they can maybe change the code they list the procedure under.  Discuss with them the issue of "cosmetic" and what makes this procedure as submitted not eligible.  Sometimes, I have found that codes used for procedures are not correct in order for reimbursement to be allowed.  They can sometimes change the code or even the procedure to fit what is eligible, if possible.  Its a place to start.  As you said, if he does not put the stiitch in, the point of the weight is moot  because your eye wont close.  (Sounds pretty straight forward, but insurance companies do not make it easy.)   So sorry you are having this difficulty.   These problems are hard enough.  Hang in there and give a call to doctor.

NYL

[alabamajane]

Hi,
You may want to call your insurance company also for further clarification of denial on cosmetic reasons as it is actually an eye health issue.

If they won't budge and Dr can't seem to change codes,, You may also try the weight without the stitch at first and see if you get enough closure for eye health. I just had the weight implanted and even though the eyelid still didn't close all the way ( about 1 mm opening Dr said) ,, I got enough help that I just used ointment at night and laying down it closed enough that I didn't have a problem with eye drying out. During the day, I just occasionally used drops , like in wind or retail stores seemed to really dry my eye....and after a year I had weight removed. My facial nerve was completely severed in surgery, so you know I had no movement for about 6 mo. ( I did have the 12/7 nerve graft after surgery though) ..

Just some other thoughts,,,,let us know what Dr says,,, maybe without stitch insurance would allow coverage.....I know you are disappointed,, but your eye health and corneal health are not cosmetic in this case.. IMO,,,,
Jane

Just some thoughts,,,

[Mimispree]

Thank you NYL and Jane;

Great minds think alike, because I did call the doctor's office and we talked about changing the code (they tried that already) and just getting the weight and forgetting about the stitch (they said that was discussed, but it didn't make any difference to the insurance company).

They sent my doctor's request further up the chain and now some higher-up may make the decision, so I am waiting on word.

In the meantime, my "good" eye is killing me!  I just went to the clinic because I was afraid it might be an infection and with possible surgery on my bad eye on Monday, I wanted to know why I had this pain.  The doctor said I don't have an infection, but it appeared the nerves around my "good" eye are causing the pain.  It feels very much like the trigeminal neuralgia pain I had before my tumor removal.

I asked him if it's because I am over-using the eye because I often wear an eye-patch on my bad eye and he said, "No."  Just like my trigeminal neuralgia I could trace the pain and it perfectly coincided with the nerves...

I'm a bit concerned because during an eye exam in December, I was told my bad eye is legally blind, and my other eye was having response problems.

Has anyone gone through this?