Is Milia Removal Covered by Insurance?

Determining whether health insurance covers milia removal involves understanding the distinction between medical necessity and cosmetic procedures. This article clarifies factors influencing insurance coverage for milia removal and guides the process.

Understanding Milia and Coverage Criteria

Milia are small, pearly white or yellowish cysts that commonly appear on the skin, often around the eyes, nose, and cheeks. These keratin-filled bumps typically measure 1 to 2 millimeters in diameter. While generally harmless, their presence can sometimes lead to concerns about appearance or physical discomfort.

Insurance companies primarily cover medical procedures deemed necessary for health or functional improvement, rather than those performed solely for aesthetic reasons. This distinction is fundamental when considering coverage for milia removal. A procedure is medically necessary when it addresses a condition that affects the body’s normal functioning, causes pain, or poses a risk to health.

For milia removal, medical necessity could be established if the milia cause physical symptoms such as persistent pain, itching, or irritation. If milia are located in a sensitive area, such as near the eye, and impair vision or cause chronic discomfort, removal might also be considered medically necessary. Furthermore, if milia are prone to recurrent infection or inflammation, their removal could be justified on medical grounds to prevent further complications.

Conversely, if milia are removed purely because an individual dislikes their appearance, without any accompanying physical symptoms or functional impairment, the procedure is typically classified as cosmetic. Insurance policies generally exclude coverage for cosmetic procedures, as they are not considered essential for maintaining or restoring health. The primary determinant for coverage rests on whether the removal addresses a diagnosed medical condition or a functional issue, rather than just an aesthetic preference.

Steps to Confirm Insurance Coverage

Confirming insurance coverage for milia removal begins with a thorough medical evaluation by a qualified healthcare professional. A dermatologist or a general practitioner can accurately diagnose the condition and assess whether the milia present any medically justifiable concerns. During this consultation, the doctor will document the specific characteristics of the milia, including their size, location, and any associated symptoms like pain, irritation, or functional impairment.

The medical professional will assign specific medical codes to describe the diagnosis and the proposed procedure. For instance, an International Classification of Diseases, Tenth Revision (ICD-10) code will specify the diagnosis, such as a particular type of milia or a related skin condition. A Current Procedural Terminology (CPT) code will identify the specific removal method, such as excision or destruction of a lesion. These codes are standard identifiers used by healthcare providers and insurance companies to process claims.

After receiving a diagnosis and proposed treatment plan, contact your insurance provider. Have your policy number ready and clearly state you are inquiring about coverage for milia removal. Ask specific questions, such as whether CPT code 17110 (an example code for destruction of benign lesions) is covered when associated with ICD-10 code L72.0 (an example code for epidermal cyst, including milia).

When contacting your insurer, inquire about:

• Any pre-authorization requirements.
• Your current deductible status.
• Your co-payment amount.
• Your co-insurance percentage.

Document the date and time of your call, the representative’s name, and a reference number for the inquiry.

Financial Considerations for Removal

Once the insurance coverage status for milia removal is determined, understanding the financial implications becomes more straightforward. If the removal is deemed medically necessary and covered by your insurance plan, you will still typically be responsible for certain out-of-pocket expenses. These commonly include your deductible, the amount you must pay for healthcare services before your insurance plan begins to pay. For example, if your deductible is $1,500, you would pay the first $1,500 of covered medical expenses each year.

Beyond the deductible, you will likely encounter co-payments and co-insurance. A co-payment is a fixed amount, such as $30 to $50, paid for each doctor’s visit or service. Co-insurance is a percentage of the cost of a covered healthcare service, such as 10% to 30%, paid after your deductible has been met. For instance, if a procedure costs $200 and your co-insurance is 20%, you would pay $40. If multiple milia require several sessions for complete removal, these out-of-pocket costs can accumulate, so factor in potential follow-up appointments.

If milia removal is considered cosmetic and is not covered by insurance, you will be responsible for the full cost of the procedure. The cost for cosmetic milia removal can vary widely depending on the number of lesions, their location, and the practitioner’s fees. Consultation fees might range from $50 to $200, and the removal itself could be charged per lesion or per session, potentially ranging from $100 to $500 or more per session. Factors such as specialized techniques or a highly experienced dermatologist can also influence the overall price.

For procedures not covered by insurance, various payment options may be available. Many clinics offer payment plans that allow you to pay for the service in installments over several months. Additionally, health savings accounts (HSAs) and flexible spending accounts (FSAs) can be utilized to pay for qualified medical expenses, including some cosmetic procedures if deemed medically necessary by a physician, using pre-tax dollars. These accounts allow individuals to save money specifically for healthcare costs, potentially reducing the overall financial burden.