Kelly Blackwell is a Certified Senior Advisor (CSA)®. She has been a healthcare professional for over 30 years, with experience working as a bedside nurse and as a Clinical Manager. She has a passion for educating, assisting and advising seniors throughout the healthcare process.
What Dermatology Procedures are Covered by Medicare?
Dermatology is a specialized branch of medicine that focuses on the prevention, diagnosis, and treatment of skin, hair, nail, and mucous membrane disorders. Dermatologists have advanced medical training and are considered by Medicare to be specialists.
Your skin is your first line of defense against injury and disease. Disorders of the skin are common, can range from mild to severe, and sometimes require the services of a dermatologist.
Medicare coverage for dermatologic procedures depends on whether or not they are deemed medically necessary, that is to evaluate, diagnose or treat a specific medical disease, illness, injury, condition, or symptoms that meet accepted standards of medicine.
Medicare does not cover dermatologic procedures that are routine (like a whole-body skin exam) or cosmetic (like laser hair removal or acne treatment) in nature. Cosmetic procedures are NOT covered unless you need them because of accidental injury or to improve the function of a malformed body part. For instance, breast reconstruction would be covered if you had a mastectomy for breast cancer.
Following the guideline of medical necessity, examples of dermatology procedures that are covered by Medicare are:
- Excision (cutting away) of a skin lesion to prevent the disease from spreading
- Laser surgery (using light beams instead of instruments) to remove a tumor
- Biopsy (taking a sample of skin tissue) to diagnose, rule out or treat cancer
- Cryotherapy (use of extreme cold) to treat tumors
- Mohs surgery (a type of procedure) to remove skin cancer
- Skin graft of healthy skin to replace damaged skin after injury
Examples of cosmetic (to improve your appearance) dermatology procedures that would NOT be covered are:
- Liposuction to suck fatty tissue from the body
- Tummy tuck
- Laser hair removal
Sometimes the distinction between what Medicare will cover or not isn’t obvious. Some examples of procedures that may be cosmetic but may also be medically necessary to treat a condition or disease are:
- Surgery on your eyelid to remove droopy, fatty, or excess tissue, if it impairs your vision,
- Botox injections, if used to treat muscle spasms or twitches,
- Surgery to remove excess skin and tissue from the lower abdomen, to prevent skin ulcers and irritation,
- Surgery to change the shape of your nose, to correct breathing problems and prevent sinus infections,
- Surgery to treat varicose veins, improve circulation, and minimize pain and inflammation.
You can access Medicare-covered dermatology services through Original Medicare or a Medicare Advantage (MA) plan. To ensure that your dermatology procedure is covered, it is always best to ask your provider or insurance plan if Medicare will help pay. Deductibles, copays, and coinsurance will apply. You may need prior authorization, especially if the service is sometimes considered cosmetic, and if you need to have a procedure outside your doctor’s office, at an outpatient surgery center.
Does Medicare Require a Referral to See a Dermatologist?
A referral is a written order from your primary doctor for you to see a specialist. If you need a referral because of the type of insurance you have and you don’t get one, your plan may not pay for the services. Referrals can offer a layer of protection for you to minimize your out-of-pocket costs and to promote continuity of care and good communication among your healthcare providers.
Referrals to specialists are generally not required with Original Medicare and some types of Medicare Advantage plans, but in the case of dermatology, it’s a good idea to ask if one is needed for your particular situation. You must have a specific medical or surgical dermatologic condition for Medicare to pay, and the dermatologist must be a Medicare-approved provider.
If your primary care physician notices a suspicious sign of a skin disorder (for instance a mole that has changed in appearance) during a visit and refers you to a dermatologist for further assessment, that dermatology visit is covered. If your skin, hair, nails, or mucous membranes are not responding to treatment recommended by your primary physician, he or she may refer you to a dermatologist for specialized management.
As an alternative to Original Medicare, if you have a Medicare Advantage (MA) plan, and it is a:
- Health Maintenance Organization (HMO) plan or Special Needs Plan (SNP), you will need a referral for these specialist services, and possibly prior authorization.
- Preferred Provider Organization (PPO) plan, you don’t need to have a referral to see a dermatologist, but if you use your plan’s in-network specialist, your costs will be lower than if you use an out-of-network provider.
- Private Fee-for-Service (PFFS) plan, you will not need a referral to a specialist, but you do need to see a Medicare-approved dermatologist that accepts your plan’s payment terms and agrees to treat you.
How do You Find a Dermatologist That Accepts Medicare?
- Your location,
- Type of provider (in this case, choose physician/clinician)
- Specialty (in this case, using the drop-down menu, choose dermatology).
Then you will click the search button and be able to review and compare dermatologists in your area.
Along with location and contact information, each provider should indicate whether or not their charges will be the same as the Medicare-approved amount for their services. This means you won’t be billed for more than the Medicare deductible and coinsurance and will keep your out-of-pocket expenses as low as possible.
Once you decide which provider you want to use, it is a good idea to contact their office to verify their location, ask if they are accepting new Medicare patients, and if you need a referral. With Original Medicare, you do not typically need a referral if you see a specialist who is enrolled in Medicare. Your primary care doctor may recommend a dermatologist to you as well.
If you access Medicare-covered dermatology services through a Medicare Advantage (MA) plan, you should contact your plan or ask your primary care provider which dermatologists they would recommend who are in-network. If you don’t need a referral, you can use the provider finder tool online at Medicare.gov. It is always a good idea to contact the specialist’s office to make sure they accept Medicare.
Kelly Blackwell, Certified Senior Advisor®