Does Medicare Cover Plastic Surgery After Mohs Surgery?

Understanding Mohs Surgery and Reconstructive Procedures

Mohs surgery is a precise method for treating certain skin cancers, including basal cell carcinoma and squamous cell carcinoma. This procedure involves removing thin layers of skin, one at a time, and immediately examining each layer under a microscope to ensure all cancer cells are removed while sparing healthy tissue. The process continues until no cancer cells remain, aiming for the highest cure rate and minimizing the amount of tissue removed. This technique is particularly valuable for cancers on cosmetically sensitive areas like the face, ears, and nose, where preserving healthy tissue is paramount.

Following Mohs surgery, a wound or defect remains where the cancerous tissue was removed. The size and location of this defect vary depending on the extent of the cancer. While some small wounds may heal on their own, many require further intervention, especially those in prominent or functional areas.

Reconstructive surgery aims to repair these defects, restoring both the appearance and function of the affected area. This differs from purely cosmetic surgery, which enhances appearance without addressing a functional impairment or defect. Reconstructive techniques can range from simple stitching of the wound to more complex procedures like skin grafts, where skin is taken from another part of the body, or local flaps, where adjacent tissue is rearranged. The goal is to achieve the best possible aesthetic and functional outcome, ensuring the treated area integrates well with the surrounding skin.

Medicare Coverage Principles for Reconstructive Surgery

Medicare, the federal health insurance program for individuals aged 65 or older and certain younger people with disabilities, covers reconstructive surgery when it is deemed medically necessary. The distinction between reconstructive and cosmetic procedures is crucial for Medicare coverage. Medicare generally covers procedures that restore function or correct a defect resulting from an injury, disease, or birth anomaly. Plastic surgery performed after Mohs surgery to repair a surgical defect and restore normal appearance or function is typically covered.

The paramount criterion for Medicare coverage of reconstructive surgery is “medical necessity.” This means the procedure must be required for diagnosis or treatment of an illness, injury, condition, or disease, or to improve a malformed body part’s function. For defects following Mohs surgery, medical necessity is established when the reconstruction aims to restore the physical integrity of the body part, prevent complications, or address disfigurement that impacts daily life. For instance, reconstructing an eyelid after cancer removal to restore its protective function is considered medically necessary.

Medicare Part B (Medical Insurance) is typically the primary payer for physician services and outpatient procedures, which includes most Mohs surgery and subsequent reconstructive procedures. This part of Medicare helps cover doctor visits, outpatient hospital care, and other medical services. Beneficiaries are generally responsible for a deductible and coinsurance, typically 20% of the Medicare-approved amount after the deductible is met.

For more extensive reconstructive procedures requiring an inpatient hospital stay, Medicare Part A (Hospital Insurance) would provide coverage. This part covers inpatient hospital care, skilled nursing facility care, and some home health services. However, most Mohs-related reconstructive surgeries are performed in an outpatient setting under local anesthesia.

Medicare Advantage Plans (Part C), offered by private companies, must cover at least all the services that Original Medicare (Parts A and B) covers. Many Medicare Advantage plans also offer additional benefits. If you have a Medicare Advantage plan, consult your specific plan’s details, as coverage rules and prior authorization requirements might differ slightly from Original Medicare, though the underlying principle of medical necessity for reconstructive surgery remains consistent.

Steps for Securing Medicare Coverage

Securing Medicare coverage for reconstructive surgery after Mohs requires careful attention to documentation and procedural steps. Thorough justification from the treating physician is required. Medical records must clearly demonstrate the medical necessity of the reconstructive procedure, detailing how it aims to restore function, prevent complications, or correct a significant disfigurement caused by the Mohs surgery. This documentation is essential for supporting the claim.

Healthcare providers often work closely with patients to navigate the billing and claims submission process. This includes ensuring procedure codes (CPT) and diagnosis codes (ICD-10) accurately reflect the medical necessity of the reconstructive surgery. Incorrect coding can lead to claim denials, requiring additional effort to resolve. The provider’s billing department typically submits claims directly to Medicare or the patient’s Medicare Advantage plan.

Depending on the specific procedure and the patient’s Medicare plan, prior authorization may be required before the surgery is performed. Prior authorization is an approval from the insurance plan indicating coverage. Failure to obtain necessary prior authorization can result in the denial of a claim, leaving the patient responsible for the full cost of the procedure. Patients or their providers should contact the Medicare administrative contractor or Medicare Advantage plan to confirm if prior authorization is needed.

Patients should also understand their potential out-of-pocket costs, which may include deductibles, coinsurance, and copayments. For Original Medicare Part B, after the annual deductible is met, patients typically pay 20% of the Medicare-approved amount for most doctor services, outpatient therapy, and durable medical equipment. Discuss expected expenses with the provider’s billing office in advance.

If a claim is denied, Medicare beneficiaries have the right to appeal the decision. The appeals process involves several levels, starting with a redetermination by the Medicare administrative contractor. If the appeal is still denied, it can escalate to higher levels, including reconsideration by a Qualified Independent Contractor (QIC) and further administrative law judge hearings. Adhere to specified timelines for appeals and provide any additional requested documentation to support the claim.