Does Medicare Cover Removal of Skin Tags?

Skin tags are common, benign growths often found in areas of friction like the neck, armpits, or eyelids. While generally harmless, they can sometimes cause discomfort or become a cosmetic concern. Many people wonder if their health insurance, particularly Medicare, will cover the cost of removing these skin growths. Understanding Medicare’s specific guidelines for medical procedures, including skin tag removal, is important for beneficiaries.

Medical Necessity and Medicare Coverage

Medicare coverage for skin tag removal is based on medical necessity, meaning it must be required to diagnose, treat, or manage a health condition. If a skin tag is removed purely for aesthetic reasons, Medicare generally considers it a cosmetic procedure and will not cover the cost. This distinction is important because Medicare specifically excludes coverage for cosmetic procedures, as they are not considered essential for maintaining or improving health.

Skin tag removal is medically necessary if the growth causes specific symptoms or interferes with bodily functions. Symptoms include persistent irritation or chafing, bleeding, infection, obstructed vision, impaired movement, or suspicion of malignancy. This coverage usually falls under Medicare Part B, which addresses outpatient services and preventive care. A healthcare provider plays a crucial role in determining this medical necessity and must document the specific health problem the skin tag is causing to support coverage.

Steps for Medicare-Covered Removal

If a skin tag is causing symptoms that suggest medical necessity, schedule an appointment with a primary care physician or dermatologist. The doctor will examine the skin tag and determine if its removal meets Medicare’s medical necessity criteria. This examination and the subsequent diagnosis are crucial for documenting the reason for removal.

During this consultation, the healthcare provider will discuss removal methods, such as excision, cryotherapy, or cauterization. The choice of method typically does not influence Medicare coverage, as long as medical necessity is established. The doctor’s office will then prepare to submit a claim using specific billing codes, including an ICD-10 diagnosis code, like L91.8, and a CPT procedural code, such as 11200. If the provider anticipates that Medicare might not cover the service, even if medically necessary, they may issue an Advance Beneficiary Notice of Noncoverage (ABN). This form informs the beneficiary that they may be financially responsible for the service if Medicare denies the claim.

Costs, Non-Coverage, and Appeals

Even when medically necessary and covered by Medicare Part B, beneficiaries are responsible for out-of-pocket costs. After meeting the annual Part B deductible, which is $257 in 2024, Medicare typically covers 80% of the Medicare-approved amount for the service. The beneficiary is responsible for the remaining 20% coinsurance. Some providers may also charge an excess amount, up to 15% above the Medicare-approved rate, if they do not accept Medicare assignment.

If a skin tag removal is purely cosmetic, Medicare will not cover the cost, and the beneficiary is responsible for 100% of the charges. It is advisable to discuss potential costs with the healthcare provider upfront, especially if there is uncertainty about Medicare coverage. If Medicare denies a claim for a removal that the patient believes was medically necessary, beneficiaries have the right to appeal the decision.

The appeals process typically begins with reviewing the Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) to understand the reason for the denial. A formal appeal, often starting with a redetermination request, can then be filed within a specified timeframe, usually 120 days from the denial notice. Providing supporting documentation from the doctor, explaining the medical necessity, can strengthen the appeal. There are multiple levels of appeal, and beneficiaries can continue to challenge the decision if they disagree with the outcome at each stage.