Eyelid surgery at Gesy. Reimbursement rules for the procedure have changed.

Gesy is changing the rules for approving upper eyelid surgery. The most important criterion for reimbursement for blepharoplasty will be the documented impact of a drooping eyelid or excess skin on the patient's field of vision. Procedures performed solely for aesthetic reasons will continue to be excluded from the system.

The Health Insurance Organization has announced new criteria for plastic surgeons and ophthalmologists collaborating with Gesy. Before performing the reimbursed procedure, consent will be required, along with medical documentation, visual field test results, and relevant X-rays.

One of the previous criteria has been abolished

The most important change concerns the efficiency of the levator muscle of the upper eyelid, which is responsible for lifting the eyelid and enabling the eye to open.

Previously, one of the criteria for approval of the procedure was a measurement of less than 8 millimeters. This criterion has been abolished. The measurement must still be included in the application, but its result will no longer be the sole determinant of reimbursement.

For the patient, this means that normal or higher muscle function should not automatically rule out surgery if tests confirm that a drooping eyelid or excess skin is indeed limiting vision.

When can Gesy cover blepharoplasty?

Upper eyelid procedures are covered if there is a documented medical indication. Dissatisfaction with the appearance of the eyes or a desire for facial rejuvenation are not sufficient.

For patients aged 9 to 80, documentation should confirm:

• reduction of the peripheral field of vision by at least 30 percent,
• MRD1 value below 3 millimeters,
• the relationship between eyelid problems and vision deterioration.

MRD1 is the distance between the reflection of light on the cornea and the edge of the upper eyelid when looking straight ahead. This measurement helps assess the degree of eyelid ptosis.

If the cause is blepharochalasis, or significant excess skin on the upper eyelid, the doctor must also demonstrate that the skin is preventing the eye from fully opening and limiting the field of vision. It is also necessary to rule out other causes of the condition.

Without prior consent there will be no refund.

Patients should not assume that simply being referred for surgery automatically means that Gesy will cover the costs. The doctor must first submit a prior authorization request.

The visual field test results must be included in the documentation. The document must clearly display the patient's name and the date of the test.

The ophthalmologist performing the examination also prepares a medical report indicating the percentage of peripheral vision impairment. The document must include a signature, stamp, and date.

You will need four photos

A standard application for a patient aged 9 to 80 should include four photographs:

• photo taken from the front while looking straight ahead, with a relaxed face,
• frontal photo with raised eyebrows,
• left profile photo,
• right profile photo.

The photographs are intended to enable assessment of eyelid position, excess skin, and the effect of eyebrow lifting on eye opening.

Separate rules for children and people over 80

For patients over 80 years of age with drooping eyelids or excess skin, two photographs are required: one with the eyebrows raised and one without them raised.

Separate requirements apply to children under 9 years of age who experience ptosis. Photographic documentation is also required in these cases.

If the problem is associated with a neurological condition, such as facial palsy, the application must be accompanied by a neurologist's evaluation and a complete medical history. This should also include information about previous eyelid surgery.

Lower eyelids without reimbursement

The Health Insurance Organization emphasizes that surgeries performed to remove excess skin from the lower eyelids are considered aesthetic procedures. Gesy does not reimburse them.

The change in criteria does not mean universal funding for blepharoplasty. However, it does expand the possibility of individual patient assessment when tests confirm a true visual impairment.

Anyone considering surgery should first consult with an ophthalmologist or a surgeon participating in Gesy. The doctor will assess whether there are medical indications, order a visual field test, and prepare the documentation needed for consent.

Sources: Health Insurance Organization, Phileleftheros