BLEPHAROPLASTY COVERAGE DOCUMENTATION CHECKLIST
SurgeryViz.com/resources/coverage-documentation-checklist

START WITH THE EXACT PLAN
[ ] Current medical policy or coverage criteria requested
[ ] Cosmetic exclusions and functional-service rules identified
[ ] Network, referral, and prior-authorization rules confirmed
[ ] Policy effective date and call reference number saved

ASK THE TREATING OFFICE
[ ] Symptoms and daily impact documented accurately
[ ] Examination findings and procedure named
[ ] Required clinical photographs discussed
[ ] Required measurements or testing confirmed before arranging them

TRACK THE SUBMISSION
[ ] Submitting clinician or billing contact identified
[ ] Records sent and date recorded
[ ] Authorization or claim reference number saved
[ ] Written approval, denial, or request for more information retained

IF THE ANSWER IS NO OR UNCLEAR
[ ] Reason and policy section requested in writing
[ ] Correction, peer review, and appeal options requested
[ ] Deadlines and required forms recorded
[ ] Self-pay quote kept separate from coverage questions

PLAN / PAYER:
POLICY OR DOCUMENT NAME:
EFFECTIVE DATE:
PHONE / REFERENCE NUMBER:
NOTES:

Educational planning only. This checklist does not determine coverage, establish
medical necessity, interpret tests, provide insurance advice, or predict approval.
Confirm current requirements with the insurer and treating clinician's billing office.