What Is Mohs Surgery and How Medicare Covers It
Mohs micrographic surgery, commonly called Mohs surgery, is a specialized technique used primarily to treat skin cancer, especially basal cell carcinoma and squamous cell carcinoma. During the procedure, a dermatologic surgeon removes thin layers of cancerous skin one at a time and examines each layer under a microscope during the surgery itself. This real-time examination allows the surgeon to see exactly where cancer cells remain and remove only the affected tissue while preserving as much healthy skin as possible. The procedure is highly effective, with cure rates ranging from 97% to 99% for primary skin cancers, making it one of the most successful treatments for certain types of skin cancer.
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Medicare, the federal health insurance program for people age 65 and older and certain younger individuals with disabilities, recognizes Mohs surgery as a covered procedure when medically necessary. Medicare Part B, which covers outpatient hospital services and physician services, typically pays for Mohs surgery performed in an outpatient setting. The coverage includes the surgeon's fee, facility costs, pathology services, and related medical supplies needed during the procedure. However, Medicare's payment structure means you will likely have out-of-pocket costs, including your Part B deductible, coinsurance, or copayments, depending on your specific coverage plan.
Understanding how Medicare reimburses for Mohs surgery involves knowing that Medicare uses a fee schedule based on Relative Value Units, or RVUs. These units account for the surgeon's work, practice expenses, and malpractice costs. For Mohs surgery, reimbursement varies based on the complexity of the case, the location of the cancer on the body, and the number of stages required. In 2024, Medicare reimbursement for a single-stage Mohs procedure ranges from approximately $500 to $800, depending on your geographic location, with higher payments in areas with higher costs of living.
Practical takeaway: Before scheduling Mohs surgery, contact your Medicare plan to confirm coverage details specific to your situation, including whether your chosen surgeon participates with Medicare and what your personal cost-sharing amounts will be.
Medicare Part B Coverage and Your Out-of-Pocket Costs
Medicare Part B is the portion of Original Medicare that covers physician services, including dermatologists and surgeons who perform Mohs procedures. When you receive Mohs surgery from a Medicare-participating provider, Medicare will pay 80% of the approved amount after you meet your annual Part B deductible. For 2024, the Part B deductible is $240 per year. Once you pay this deductible, you are responsible for the remaining 20% coinsurance for the Mohs surgery procedure. This means if Medicare approves $600 for your Mohs surgery, you would owe 20% of $600, which equals $120, assuming you have already met your deductible for the year.
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If your dermatologist or surgeon does not participate with Medicare (called a non-participating provider), your costs increase significantly. Non-participating providers can charge up to 15% more than the Medicare-approved amount, and Medicare will still only pay 80% of its approved fee. This creates a larger gap between what Medicare pays and what the provider charges. Additionally, non-participating providers may bill you for the difference, which is called balance billing. It is therefore important to verify before scheduling that your surgeon participates with Medicare to control your costs.
Your actual out-of-pocket costs depend on several factors beyond the procedure itself. Facility fees vary between hospital outpatient departments and standalone surgical centers. A hospital outpatient facility may charge facility fees in addition to the surgeon's fee, while an ambulatory surgical center (ASC) may have different fee structures. Laboratory costs for pathology services, where the tissue samples are examined microscopically, are also covered by Medicare but contribute to your total costs. If the Mohs procedure requires multiple stages—meaning the surgeon needs to remove and examine multiple layers—your costs increase proportionally.
Practical takeaway: Before your Mohs surgery, request a detailed cost estimate from your surgeon's office that includes the surgeon's fee, facility fee, pathology costs, and any other charges. Contact Medicare or your plan to understand your deductible status for the year and confirm your coinsurance percentage.
Medicare Advantage Plans and Mohs Surgery Coverage
Medicare Advantage Plans, also called Part C plans, are an alternative to Original Medicare offered by private insurance companies approved by Medicare. These plans must cover everything that Original Medicare covers, including Mohs surgery, but they may have different cost-sharing structures, different provider networks, and additional coverage options. Most Medicare Advantage Plans cover Mohs surgery through their outpatient surgery benefits, but the specific costs you pay vary significantly between plans and between insurance companies.
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Many Medicare Advantage Plans structure their cost-sharing for outpatient surgery using copayments rather than coinsurance percentages. For example, one plan might charge a $150 copay for outpatient surgery, while another might charge $300 or more. Some plans use tiered networks, meaning you pay less if you use an in-network dermatologist or surgeon and more if you go out of network. A few plans still use coinsurance, where you pay a percentage like 20%, similar to Original Medicare. The important distinction is that your total costs under a Medicare Advantage Plan for Mohs surgery are typically capped at the plan's out-of-pocket maximum, which cannot exceed $7,550 for in-network services in 2024. Original Medicare has no out-of-pocket maximum.
When evaluating Medicare Advantage Plans during the Annual Enrollment Period (October 15 to December 7 each year), it is important to review whether your preferred dermatologist participates in the plan's network. If your dermatologist is not in the network, you would pay the out-of-network cost-sharing amount, which is typically much higher. Additionally, some Medicare Advantage Plans require prior authorization before Mohs surgery, meaning your surgeon must obtain approval from the insurance company before proceeding. This process typically takes a few days and is usually straightforward for medically necessary Mohs procedures, but it is an extra step to anticipate.
Practical takeaway: Review your Medicare Advantage Plan's Summary of Benefits and Coverage document annually, specifically looking at outpatient surgery costs and your dermatologist's network status. If Mohs surgery is anticipated, confirm whether prior authorization is required and contact your plan's member services for a cost estimate specific to your plan.
When Medicare Covers Mohs Surgery and Medical Necessity
Medicare covers Mohs surgery when it is considered medically necessary, which means a physician determines that the procedure is appropriate for your condition. Generally, Medicare covers Mohs surgery for the treatment of non-melanoma skin cancers, primarily basal cell carcinoma and squamous cell carcinoma. Mohs surgery is considered the standard of care for skin cancers in certain high-risk areas, such as the face, ears, hands, feet, and genitals, where preserving healthy tissue and achieving the best cosmetic outcome is particularly important. In these locations, Mohs surgery's high cure rate and tissue-sparing approach make it an especially valuable treatment option.
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Medicare may also cover Mohs surgery for skin cancers in lower-risk areas, such as the trunk or limbs, depending on specific characteristics of the cancer. Factors that influence coverage decisions include the size of the cancer, whether it is a first occurrence or a recurrent cancer, the aggressiveness of the cancer cells, and whether the cancer is in an area where conventional surgical removal would cause significant cosmetic or functional problems. If a cancer is particularly large, recurrent, or located in an area where preserving tissue is important, Medicare is more likely to consider Mohs surgery medically necessary and therefore covered.
It is important to note that Medicare does not cover Mohs surgery for cosmetic purposes alone or for the removal of benign skin lesions that are not cancerous. If a dermatologist recommends removing a mole or other skin growth for cosmetic reasons rather than because it is cancerous, Medicare will not cover that procedure. Additionally, Medicare does not cover Mohs surgery performed at retail clinics or walk-in dermatology centers that do not have the proper licensing and laboratory facilities to perform the procedure according to Medicare's standards. The procedure must be performed by a qualified dermatologic surgeon in an appropriate medical setting.
Practical takeaway: Before scheduling Mohs surgery, ask your dermatologist why they are recommending this specific procedure for your skin cancer and ensure they explain how it meets medical necessity criteria. Request that your surgeon's