The Cosmetic Exclusion
Medicare law excludes cosmetic surgery and related expenses, except when required for prompt repair of accidental injury or improvement of a malformed body member. Most commercial plans follow similar rules.
Benign Lesions That Can Be Covered
Removing a benign lesion such as a seborrheic keratosis or skin tag is covered only when documented symptoms or findings make it medically necessary.
- Bleeding, intense itching or pain
- Inflammation, infection or recent change in appearance
- Physical irritation from clothing or jewelry, or obstruction of vision or a body opening
- Clinical uncertainty about the diagnosis that requires removal to rule out malignancy
Notices And Modifiers
When a Medicare service may be denied as not medically necessary, an Advance Beneficiary Notice (ABN) given before the service lets the practice bill the patient if Medicare denies. Services that are excluded by statute, like cosmetic procedures, do not require an ABN, but one can be given voluntarily.
- GA: a required ABN is on file
- GZ: the service may be denied as not medically necessary and no ABN is on file
- GY: the service is statutorily excluded or does not meet the definition of a benefit
- GX: a voluntary ABN was issued for an excluded service
Collecting For Cosmetic Services
Cosmetic services are best handled with a clear self-pay policy and a signed financial agreement before treatment. Mixing covered and cosmetic services on one claim invites denials and patient billing errors.
Frequently Asked Questions
- Can I bill Medicare for a skin tag removal the patient wants for appearance?
- No. Without documented symptoms it is cosmetic. Bill the patient directly, and use GY if a claim is filed for a denial the patient needs for secondary insurance.
Billing Support For This Specialty
Physicians Professional Billing Services, Inc. has billed wound care, surgical and procedural specialties since 1998, across every Medicare Part B MAC jurisdiction.
Primary Sources
This page is general information about billing and coverage rules and is not legal, coding or reimbursement advice for a specific claim. Coverage policies change; confirm current requirements with CMS and the applicable Medicare Administrative Contractor.