Is Plastic Surgery After Mohs Covered by Insurance?

Mohs surgery is a precise method for removing skin cancer, often leaving a defect that requires subsequent repair. Reconstructive surgery, frequently performed by plastic surgeons, addresses these defects to restore function and appearance. Understanding insurance coverage for these procedures can alleviate financial concerns.

Understanding Mohs Surgery and Reconstruction

Mohs micrographic surgery removes skin cancer layer by layer, meticulously examining each layer under a microscope until no cancer cells remain. This precise technique minimizes tissue removal, making it valuable for cancers in cosmetically sensitive or functionally critical areas. Despite its precision, Mohs surgery can still result in a wound or defect.

These post-surgical defects often necessitate further repair, especially when located on the face, ears, or other visible areas. Reconstructive surgery focuses on restoring the body part’s normal function and appearance. Plastic surgeons are often involved due to their specialized training in soft tissue repair, skin grafts, and local flaps.

A crucial distinction for insurance coverage exists between reconstructive and cosmetic plastic surgery. Reconstructive surgery is medically necessary, correcting defects caused by disease, injury, or birth abnormalities. Cosmetic surgery is elective, performed solely to enhance appearance without addressing a medical condition.

Insurance Principles for Reconstructive Surgery

Insurance coverage for reconstructive surgery following Mohs procedures depends on “medical necessity.” This term signifies a service is appropriate and consistent with accepted medical practice, typically defined as a procedure for the diagnosis, treatment, or relief of a health condition, illness, injury, or disease.

Policies usually cover procedures designed to restore function, such as repairing an eyelid to restore vision or reconstructing a nose for proper breathing. Coverage also extends to procedures that restore appearance after disfiguring conditions like cancer removal.

Purely cosmetic procedures, even if performed by a plastic surgeon, are generally not covered by insurance. For example, a procedure solely to improve aesthetic symmetry without functional impairment might be deemed cosmetic. While medical necessity is the overarching rule, specific definitions and covered services can vary among different insurance policies and providers.

Factors Influencing Coverage Decisions

Thorough medical documentation from both the Mohs surgeon and the reconstructive surgeon influences coverage decisions. Proper medical coding, including ICD-10 codes for diagnosis and CPT codes for procedures, is essential to communicate medical necessity to the insurer.

The type of insurance plan a patient holds also affects coverage, particularly regarding network access and referral requirements. Common plan types include:
Preferred Provider Organization (PPO) plans often offer a wider network and allow patients to see specialists without referrals, though out-of-network care may incur higher costs.
Health Maintenance Organization (HMO) plans typically require patients to select a primary care physician and obtain referrals for specialists within a more restricted network.
Exclusive Provider Organization (EPO) plans generally do not require referrals but usually cover only in-network care.
Point of Service (POS) plans blend features of HMOs and PPOs, often requiring referrals but offering some out-of-network coverage at a higher cost.

Pre-authorization, also known as prior approval, is a step where the insurer grants approval before a procedure is performed. This process typically involves the surgeon’s office submitting detailed documentation to the insurance company to demonstrate medical necessity. Failing to obtain pre-authorization can lead to a denial of coverage, leaving the patient responsible for the full cost.

Even with coverage, patients remain responsible for out-of-pocket costs such as deductibles, co-pays, and co-insurance. Deductibles, ranging from $1,000 to over $6,000, must be paid before insurance coverage begins. Co-pays are fixed amounts for specific services, while co-insurance is a percentage of the cost after the deductible is met. Most plans also have an out-of-pocket maximum, capping the total amount a patient pays annually for covered services, often around $9,200 for individuals and $18,400 for families in 2025. Some policies may include specific exclusions or limitations, or impose waiting periods before certain benefits become active.

Navigating the Insurance Process

Patients should discuss insurance coverage directly with both their Mohs surgeon and reconstructive surgeon’s offices. Confirm that the surgical teams will coordinate with the insurer, submitting all necessary medical documentation for pre-authorization.

Contact the insurance provider directly to verify benefits and understand specific policy details. Inquire about the pre-authorization process for reconstructive surgery and confirm any required forms or timelines. Document all conversations, including the date, time, representative’s name, and any reference numbers, for a valuable record.

Upon receiving an Explanation of Benefits (EOB), patients should review it to understand covered services, denials, and reasons. The EOB details how the insurer processed the claim, including applied deductibles, co-pays, and co-insurance. This document is essential for identifying discrepancies or errors in billing and coverage.

If coverage is denied, patients have the right to appeal the decision. The appeal process typically begins with an internal appeal, where the patient or their provider requests the insurer to reconsider its decision, often within 180 days of the denial. This involves reviewing the denial letter, gathering additional supporting medical documentation from the healthcare team, and writing a formal appeal letter explaining why the service is medically necessary. Should the internal appeal be unsuccessful, patients may then pursue an external review by an independent third party, which can be requested within a specified timeframe, usually 60 to 120 days after the final internal denial.