Clearing Up Confusion about Cosmetic Surgery - Avoid Claims Denials

Dermatologists often perform procedures that are medically necessary, in addition to those that are cosmetic in nature, e.g. removing a skin tag. Confusion sometimes occurs regarding what services are covered by TRICARE.

For example, during an office visit for an authorized dermatology procedure, a TRICARE beneficiary wants a skin tag cosmetically removed. The provider removes the skin tag, but there was no medical justification because the removal was purely for cosmetic reasons. Confusion can then result when the services billed exceed the services authorized and the provider does not get paid because he/she hasn’t obtained a Waiver of Non-Covered Benefits from the beneficiary. This waiver allows a network provider to collect billed charges for services denied as ‘non-covered’ (not a TRICARE benefit) from a TRICARE beneficiary when the beneficiary has agreed, in writing, to waive his or her balance-billing protection. (Note: it is never appropriate to use a Waiver of Non-Covered Benefits for an active duty service member or bill them for non-covered services.)

According to TRICARE policy, the removal of skin lesions should be considered cosmetic and not a covered benefit unless medically proven otherwise.

Skin tag (achrocordon) removal is always considered cosmetic unless they are on the upper eyelid and hanging into the visual field.

It is important to understand that a referral for evaluation and treatment does not imply that cosmetic surgery services are covered. Just because a patient receives a referral for an evaluation doesn’t mean the treatment will be covered if the services are not a TRICARE benefit. Potentially cosmetic services require a medical necessity review and a prior authorization per the TriWest Prior Authorization List.

If you have any questions, please refer to the TriWest Prior Authorization List on www.triwest.com/provider or call 1-888-TRIWEST (874-9378).

Published Date: 03/24/2009