Does Insurance Cover Mohs Surgery? What to Know

Mohs surgery precisely removes skin cancer layer by layer, with each layer examined under a microscope until all cancerous cells are gone. This method maximizes cancer removal while preserving healthy surrounding tissue. Its high success rates, often up to 99% for certain skin cancers, make it a preferred treatment option for many individuals. Understanding insurance coverage for this specialized procedure is important for patients.

General Principles of Coverage

Mohs surgery is considered a medically necessary procedure for certain skin cancer types and locations. This medical necessity is a primary factor determining insurance coverage. Most major insurance types, including private health insurance, Medicare, Medicaid, and Affordable Care Act plans, cover Mohs surgery when it meets these criteria.

Insurance plans use several terms impacting a patient’s financial responsibility. A “deductible” is the amount an individual pays for covered healthcare services each year before their insurance plan pays a larger portion. After the deductible, “coinsurance” often applies, which is a percentage of the medical charge the patient pays, with the remaining portion covered by the plan. For example, 20% coinsurance means the patient pays 20% of approved charges, and the insurer pays 80%.

A “co-payment,” or “copay,” is a fixed amount paid for healthcare services at the time of care, such as a specialist visit. These fixed amounts do not count towards the deductible but may count towards the “out-of-pocket maximum.” The out-of-pocket maximum is the highest amount an individual will pay in a year for covered services, after which the insurance plan covers 100% of eligible costs. Whether a provider is “in-network” or “out-of-network” also affects costs, with in-network providers having negotiated rates that result in lower patient expenses.

Preparing for Mohs Surgery Coverage

Before undergoing Mohs surgery, patients should proactively verify their specific policy details to ensure maximum coverage. Contacting the insurance provider directly, by phone or online, allows patients to confirm coverage. Inquiring about specific procedure codes (CPT codes) the surgeon plans to use can clarify coverage.

Prior authorization, also known as pre-authorization or pre-approval, is often required by insurance companies for Mohs surgery. This process involves the healthcare provider obtaining approval from the insurance plan before the procedure, confirming its medical necessity. Failure to secure prior authorization can result in denied claims, leaving the patient responsible for the full cost. While the doctor’s office handles this process, patients should confirm prior authorization has been obtained and approved.

Understanding personal financial responsibility involves clarifying deductible status, co-payment amounts for specialist visits or the surgery, and co-insurance percentages. Patients should also ask how much they have already contributed towards their annual out-of-pocket maximum. Requesting a “good faith estimate” from the provider can offer a projection of anticipated charges, including facility fees and related services, for those uninsured or self-paying. Confirming that both the Mohs surgeon and surgical facility are in-network with the specific insurance plan helps manage costs.

Managing Claims and Denials

After Mohs surgery, the provider’s office submits the claim to the insurance company for processing. Patients then receive an Explanation of Benefits (EOB) from their insurer, detailing how the claim was processed and the costs covered. This EOB is not a bill, but a summary of services rendered, the amount billed, the amount covered by insurance, and the patient’s remaining responsibility. It is important to cross-reference the EOB with any separate bill from the provider to ensure accuracy.

Understanding the EOB involves reviewing information such as the date of service, service description, provider’s charges, amount paid by the insurer, and any amount the patient still owes. The EOB also includes reason codes if a claim was denied, explaining why coverage was not provided.

If a Mohs surgery claim is denied, patients have the right to appeal. First, review the EOB or denial letter to understand the specific reason. Next, contact the insurance company for clarification and to understand their internal appeal process, noting all communication.

Gathering necessary documentation, such as medical records, prior authorization confirmation, and doctor’s notes explaining the procedure’s medical necessity, is an important step. Patients should then submit an internal appeal to the insurance company, often within a specified timeframe, providing all supporting evidence. If the internal appeal is unsuccessful, patients may pursue an external review, where an independent organization reviews the claim.