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Last year almost 250,000 people in the United States underwent eyelid surgery, or blepharoplasty. Because aging causes the skin around the eye to sag, blepharoplasty has risen to become one of the most sought-after plastic surgery procedures for patients over the age of 35. The extremely thin skin making up the eyelids starts to lose its elasticity and stretch, and it's largely a hereditary condition. If your siblings and parents have saggy eyelids, you probably do as well.

Usually the removal of excess skin and fat from the eyelids is performed for cosmetic reasons. However, upper blepharoplasty can be medically necessary when the excess skin covers the eyelid margin or deflects the eyelashes downward, impairing the patient's vision.

To ensure that upper eyelid surgery is a medical necessity rather than a cosmetic condition, case managers should consider having the patient take good, high resolution photographs of the eye region. If the upper eyelid margin of the eye crosses the plain of pupil in the photo, then further testing can be done. An ophthalmologist can run a visual field mapping test on the patient. If the patient's visual interference with upper case letters is at 20 percent above horizon, and if taping the patient's eyelids back improves his or her vision 20 degrees above the horizon, then the treatment probably is required.

This, along with a documented patient medical chart showing a long standing visual issue, are strong indicators to the case manager that upper eyelid surgery is a medical necessity.