Skin Tag Removal – When is it Covered?

Dermatologists often perform procedures that are medically necessary as well as 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 not getting paid because he/she hasn't obtained a Waiver of Non-Covered Benefits from the beneficiary. (Note: it is never appropriate to use a Waiver of Non-Covered Benefits for an active duty service member.)

According to TRICARE policy, the removal of skin lesions should be considered cosmetic and not a covered benefit unless medically proven otherwise. In addition, skin tags (achrocordons) are always considered cosmetic unless they are on the upper eyelid and hanging into the visual field.

Valid indicators which may allow a skin lesion to be removed include the following:

• The lesion has irregular borders (i.e., is not round at the base, but has angular margins or "pigment leakage" into surrounding skin).
• The size is documented to have changed recently.
• The shape is documented to have changed recently.
• The coloration is documented to have changed recently.
• The lesion is in an area where clothing traumatizes it (e.g., under a collar area, bra strap, waistband, etc.).
• The lesion is a wart or plantar wart.

TriWest Healthcare Alliance has determined that if the skin tag or lesion meets the valid indicators for removal, an authorization is no longer needed and the removal will be bundled with the office visit claim. A Prime beneficiary still needs a referral to a dermatologist.

Please visit www.triwest.com or call 1-888-TRIWEST (888-874-9378) for more information.