Are Skin Tag Removals Covered by Insurance?

Skin tags are common, benign, flesh-colored growths extending from the skin. They form where skin rubs against skin or clothing, such as the neck, armpits, or groin. While harmless, insurance coverage for their removal depends largely on whether the procedure is considered medically necessary rather than purely cosmetic. Insurance policies vary, so coverage is not universal.

Medical Necessity and Coverage Criteria

Insurance providers distinguish between removing skin tags for medical reasons and for aesthetic concerns. A removal is considered medically necessary if the skin tag causes specific symptoms or functional impairment. These symptoms include persistent pain, bleeding, or itching, especially from friction.

Medical necessity also applies if the skin tag interferes with bodily functions, such as obstructing vision if located on an eyelid or impeding movement in areas like the armpit or groin. If a skin tag exhibits suspicious changes in size, color, or shape, raising concerns about potential malignancy, its removal for pathological examination is covered. A medical professional must make this determination based on a clinical examination. Purely cosmetic removals, driven solely by appearance, are not covered by insurance.

The Insurance Claim Process

Once a medical professional determines skin tag removal is medically necessary, seeking insurance coverage requires thorough documentation from the treating physician. This includes detailed medical notes describing the symptoms, location, and size of the skin tag, along with the medical justification for its removal. Insurers may also require photographs as supporting evidence.

Patients should obtain specific coding information from their doctor’s office, including Current Procedural Terminology (CPT) codes and International Classification of Diseases, Tenth Revision (ICD-10) codes. CPT code 11200 is commonly used for the removal of up to 15 skin tags, with 11201 used for each additional 10 lesions. ICD-10 codes, such as L91.8 for irritated skin tags or L98.8 for inflamed or bleeding ones, justify the medical necessity.

Many insurance plans require pre-authorization or pre-certification before a medically necessary procedure is performed. This process typically involves the doctor’s office submitting paperwork to the insurer for approval before the removal. After the procedure, the provider’s office usually submits the claim directly to the insurance company. Patients will then receive an Explanation of Benefits (EOB), which details the approved and denied amounts, as well as the patient’s remaining responsibility. If a claim for a medically justified removal is denied, an appeal process can be initiated, often requiring additional documentation or a formal appeal letter to the insurer for review.

Understanding Out-of-Pocket Costs

Even when skin tag removal is deemed medically necessary and covered by insurance, patients incur various out-of-pocket expenses. A deductible is the initial amount a patient must pay for covered services before their insurance plan begins to contribute. If a plan has a $1,000 deductible, the patient pays the first $1,000 in covered medical expenses.

After the deductible is met, copayments and coinsurance may apply. A copayment is a fixed dollar amount paid for a specific service, such as a doctor’s visit, often collected at the time of service. Coinsurance represents a percentage of the cost of covered services that the patient is responsible for, such as 20% of the total bill, with the insurer covering the remaining percentage.

For removals considered cosmetic or in cases where coverage is denied, patients are responsible for the full cost. Patients should discuss the total cost with the provider’s office beforehand, as prices can vary based on the number of tags and removal method. Patients may explore options like cash payments or payment plans with the provider. Patients should have skin tags removed by a qualified medical professional to avoid risks such as infection, scarring, incomplete removal, or misdiagnosis of a more serious skin condition.