Is cosmetic mole removal covered by insurance?
July 15, 2016 8:15 AM   Subscribe

I have a prominent mole on my face that I'm just tired of looking at -- plus, it's gotten bigger since I was young. I have a consultation with a plastic surgeon soon. (I'd rather he do it than my dermatologist, to minimize the risk of scarring.) If a mole is benign, does insurance typically cover its removal?

The receptionist said that since "they don't know if it could become cancer," the first appointment (or maybe that will be the only appt. and they'll remove it then) will be submitted to insurance, and they'll be sending a biopsy to the lab anyway. The way she explained it to me (she said more than that) made me wonder if doctors ever fudge the details to make the procedure look medically necessary. Note that I am NOT going to ask my doctor to do that; I'm just wondering. I don't know if I can afford it if my insurance doesn't cover it.
posted by trillian to Health & Fitness (21 answers total) 2 users marked this as a favorite
Response by poster: I just want to emphasize again that I would never ask a doctor to do anything improper or illegal or whatever! I've just only had moles removed at the dermatologist before (if they looked odd or changed, although they've all been harmless) and it's always covered by insurance.
posted by trillian at 8:18 AM on July 15, 2016

I have had benign mole removal (by my dermatologist; it wasn't on my face) covered under my insurance plan. In my case, it was one appointment- the moles were removed, sent out to the lab, and were later determined to be benign. Your plan and your situation may vary (you may, for example, need to see a dermatologist and not a plastic surgeon to have the removal covered as medically necessary- this is just my speculation, the office staff at the practice is probably a lot more knowledgeable about the details of what their participating plans generally cover). Like the receptionist said, they can't tell in advance of removal whether the mole is benign or not, so if there's a possibility of a question, I would think the removal would be covered.

I wouldn't worry too much on your end about what is and is not fraud- insurance plans have standards of what they cover, and providers work within those standards. You wanting the mole gone for cosmetic reasons wouldn't override the insurance company covering the removal as medically necessary if that's something they do.
posted by ThePinkSuperhero at 8:26 AM on July 15, 2016

My daughter just had some weird looking moles removed. Insurance would NOT cover as it was considered cosmetic surgery. YMMV.
posted by yes I said yes I will Yes at 8:29 AM on July 15, 2016

Since it has gotten bigger, they will need to remove it to have it checked for cancer, so it should be covered. I had one that was under my eye and I could see it whenever I looked down to read. I had it removed (and they tested it) but, they only removed the puffed out part. I was offered cream to lighten it but I had tried the cream before and it triggered my asthma. I think it depends on the doctor and the insurance on how much gets removed and how it is charged.
posted by myselfasme at 8:50 AM on July 15, 2016 [1 favorite]

Call your insurance company! Geez!!

"I have a mole that has gotten bigger and needs to be removed and tested. The mole is on my face and I would rather a plastic surgeon remove it to reduce scarring. Is this still covered? How can I make sure it's still covered?"

That's it. The mole has gotten bigger, it needs to be removed. Just call your insurance company.

Nobody wants you to have s facial scar. Your situation is normal and fine. Just call and triple check. Do it the right way to make sure it's covered and doesn't leave a scar.

You are being responsible, you're not cheating the system or anything. Drop the shame and make that phone call. Make sure you take down the rep's name and ID number and take notes while on the call.

Good luck!
posted by jbenben at 9:00 AM on July 15, 2016 [12 favorites]

Best answer: Whether your insurance will cover it is based entirely on your insurance policy, and you need to find out from them - not ask the internet given the myriad of different factors at play. Any opinions about personal situations you get here are not easily applicable to your situation because you don't have the same doctor, mole, insurance plan, region, etc.

Your best bet is to start by reading your benefit plan, and then before you do any sort of work, ask that your doctor submit a pre-treatment estimate plan on your behalf to the insurance company, which will: 1) Inform you of the fee your doctor will plan to charge for the entire procedure and 2) Have your specific insurance company tell you whether they would cover the treatment in the described circumstances.
posted by Karaage at 9:01 AM on July 15, 2016 [4 favorites]

Response by poster: Regarding calling my insurance company: going by my past experiences with them, I basically have no faith that I will even get the correct information if I call. That's what they're like. And also I didn't want to call and be like, "Yeah, so this is a totally harmless, benign mole that I just don't like!" and then later the doctor's office files the claim and says it was medically necessary to remove it (which for all I know is true). Maybe the ins. company wouldn't even make a note of my call, but who knows.
posted by trillian at 9:24 AM on July 15, 2016 [1 favorite]

My sense would be that if the mole has changed shape/size (which it sounds like it has), it must be checked out. I would ask whether the office can get some type of prior authorization from your insurance company -- I've had this done for other things (not mole removal) but it's worked out well, although of course YMMV.
posted by rainbowbrite at 9:38 AM on July 15, 2016 [1 favorite]

Well, anecdotally: My bestie had a mole on her face all her life. When she was in her twenties and wanted it removed, insurance wouldn't pay for it. When she was in her early fifties and it was getting bigger, insurance did pay to have it removed.
posted by BlahLaLa at 9:43 AM on July 15, 2016

I wouldn't call the insurance company. I would say to the doctor that you cannot afford to do this without the insurance so if it is not going to be covered (cancerous moles are covered), you do not want to do it. The doctor can figure out if it is covered or if it needs to be coded in a certain way. Or the doc will say it won't be covered, call back when you saved up.
posted by AugustWest at 10:05 AM on July 15, 2016

Best answer: I work for a plastic surgeon (who does not take insurance.) In larger offices there are often insurance/billing/coding personnel, so you could call and ask to speak to the billing department specifically and/or check their office website to see if such a person exists there. Also, shop around and get a few opinions - prices may vary from practice to practice and some offices may offer no-interest financing if your insurance doesn't cover it.
posted by tatiana wishbone at 10:07 AM on July 15, 2016 [1 favorite]

Best answer: The doctor can figure out if it is covered..... Or the doc will say it won't be covered

No.nononono. The doctor is not responsible for your insurance company. People seem to conflate insurance companies with doctors all the time or think the doctor knows all of the insurance plans. The doctor is not responsible for whether your insurance pays out or not. They have insurance billers who submit the invoice to the insurance company - but their job is to ensure the doctor gets paid. If the insurance company denies benefits, the doctor comes to you to get paid. Every new patient that starts with a practice signs documents stating that the doctor is not responsible for insurance payouts, and that the patient is responsible for any balance.

As I said before, ask the doctor submit a pretreatment estimate and authorization to your insurance company. Wait until the insurance company comes back tells you how much they will cover. Proceed from there.
posted by Karaage at 10:14 AM on July 15, 2016 [3 favorites]

Best answer: No, you do not have a benign mole. You have a suspicious mole, as it has grown, which can mean it is cancerous. You not liking it for cosmetic reasons is not evidence that it is benign. Moles that grow need to be surgically removed and biopsied to determine whether or not they are benign. It will be pronounced benign or not benign based on the biopsy, not on your opinion that this is merely a cosmetic issue.

See if you can at least get it partially covered on that basis and maybe pay the difference between that and what the cosmetic surgeon charges. I used to have the tooth colored fillings done on my kids and I paid the difference out of pocket between that, which was a cosmetic thing in the eyes of the medical world, and the basic cheap fillings.
posted by Michele in California at 10:18 AM on July 15, 2016 [3 favorites]

Best answer: I wouldn't say a word about not liking it for cosmetic reasons. I would just go into the dermatologist of choice and say it has gotten bigger. That should be all you need to do. Talking about cosmetics just confuses everything.

The reason it is expensive is most doctors have to have a biopsy on EVERY mole that is removed. By law. (or by their malpractice insurance?) But I do know of one doctor who operates on a subscription basis, instead of insurance (you pay something like $100 a month to see him anytime) and somehow that makes him free to remove moles and if he feels that they don't look cancerous he does not have a biopsy done.
posted by cda at 10:37 AM on July 15, 2016 [4 favorites]

You are going to have to call your insurance. Every plan is different. I used to have a plan for example that would remove warts with just a copay but my current plan has extra fees for this kind of stuff. You need to call your insurance and read your benefits stuff. There's no way the Internet can answer this for you.
posted by FireFountain at 11:00 AM on July 15, 2016 [1 favorite]

Yeah, the only mention you should make of cosmetics should be in the vein of "Because it's on my face, I would like it handled by someone qualified to minimize the scar." But this is absolutely a medical issue. Any cosmetic concerns are secondary.

I say this as someone who had a very large mole removed from my neck because it had gotten larger and darker. I was fortunate that the person who removed it was very talented and had worked in a cosmetic surgeon's office. The scar is essentially invisible. I have trouble finding it. But the reason it was removed was to biopsy it.

I was a very vain 22 year old and happy to have my looks improved by the removal of the mole, but its removal was ordered by an MD based on the alarming changes to the mole. This is the situation you have. Yes, try to get it handled by someone sensitive to the fact that it is on your face, but when you talk to medical professionals and to your insurance company, you need to talk about this as a medical concern, not a cosmetic issue.

There is no reason to get scared. It probably is benign. But it's growth means removal is medically indicated. It should be biopsied. And that may well be covered by insurance. (I do not know. I was a military wife at the time. No insurance was involved. And, as stated above, all policies and companies are different. So call your insurance.)
posted by Michele in California at 12:36 PM on July 15, 2016 [1 favorite]

Best answer: A couple antidotal stories:

When I went to a plastic surgeon to have moles removed they absolutely wouldn't do it without a dermatologist giving the OK that they were all non cancerous, so you might end up at the dermatologist anyway, and then since its on your face ask them to give the ok to the plastic surgeon.

I had a mole on my stomach that was crappy looking, and mentioned it to my derm and how it got irritated by my pants. She lopped it off and checked that it wasn't cancerous (it wasn't) and insurance covered it no question

My husband had a mohes procedure done on his face, and the dermatologist recommended we bring him to a plastic surgeon to get the well, two inch hole they created in his face put back together properly . Even with the recommendation from the dermatologist, the insurance rejected it the first time. I don't know what magic the plastic surgeons office worked (I think it involved a change code, and a lot of "this was reconstructive, not cosmetic explanation) but it went through the second time.

TLDR: Its a crapshoot. But I would start with the dermatologist. You really need to know that it isnt cancer (it probably isnt! but be safe)
posted by zara at 1:36 PM on July 15, 2016 [1 favorite]

Best answer: I used to approve/deny health insurance claims based on what the various policies covered.

YOU NEED TO CALL YOUR INSURANCE COMPANY. Your doctor will NOT be able to give you accurate information on what will or will not be covered.

According to the policies of my former company, mole removal would be covered if it was suspicious (had grown, changed color, size, etc.) or it was located in a place that was causing discomfort (bra strap, waistband, etc.). In order to give the go-ahead for a claim, the person would have had to first seen their GP, been sent on to a dermatologist, and have the dermatologist agree that it was necessary to remove. Only after that would removal by a plastic surgeon be considered.

If you are worried about getting inaccurate information from your insurance company, make note of the day and time of the call, the full name of the person you spoke with, what they said, AND CALL AGAIN. If you get differing information, ask to speak with the manager on duty and tell them you've got conflicting info. Know that (in the US and UK) ALL CALLS ARE RECORDED and you can request a transcript in case they later deny a claim they said was okay.

One more thing: if doctors fudge results or codes to make it look like it something more serious than it is it is considered insurance fraud.
posted by Specklet at 3:52 PM on July 15, 2016 [3 favorites]

Response by poster: Looked at my insurance member contract and it says cosmetic procedures are not covered if they are "primarily intended to improve your appearance and not Medically Necessary." That's not surprising. I guess I will call on Monday and I won't refer to it as a cosmetic procedure anyway. (That's the closest thing I could find in the member contract.)
posted by trillian at 1:31 PM on July 16, 2016

Nthing crapshoot. I've had friends get things approved in advance with insurance (while keeping the proper notes) and once it's been done, insurance says they won't cover it.

Nthing don't say "cosmetic." If it has grown, it needs to be removed - take it from Skin Cancer McGee over here. (That's me)

Good luck!
posted by getawaysticks at 12:14 PM on July 17, 2016

Response by poster: So... I read my coverage details and then called my insurance, and they said they had to have a procedure code to give me an answer. I said I didn't have one, and they asked if they could call the doctor's office to ask. They did, and the office said they couldn't give one yet. I went to the appt. and asked the desk person about the code when I was checking out. She said to call back the next day because the doctor usually does the codes in the evenings. I thought it would be more straightforward, but nope. I still have to call the doctor's office to ask them the code and then call insurance again. I'll try to update this thread just in case it's helpful to anyone else in the future.
posted by trillian at 9:32 AM on August 11, 2016

« Older Young Adult book about a girl who works for the...   |   tv shows on Netflix: real emotions... Newer »
This thread is closed to new comments.