Milia are small, pearly-white bumps that form just beneath the surface of the skin. They are tiny cysts filled with keratin, a strong protein found in skin tissues, hair, and nails. While common in newborns, milia also appear in adults, most often on the face, particularly around the eyes and cheeks. Since these lesions generally pose no health risk, individuals often question whether health insurance covers professional removal.
Classifying Milia Removal as Medical or Cosmetic
Health insurance coverage is determined by whether a procedure is classified as medically necessary or purely cosmetic. Medically necessary treatments address conditions affecting the body’s function or overall health, while cosmetic procedures solely improve appearance. Milia removal is presumed to be a cosmetic procedure by insurance providers, since the lesions are benign and typically asymptomatic.
To qualify for coverage, the removal must be linked to a functional impairment or a documented health risk, not just an aesthetic concern. A healthcare provider must clearly document a medical rationale in clinical notes to establish that the milia are causing a problem that extends beyond simple appearance.
Specific Conditions for Insurance Coverage
Insurance companies may classify milia removal as medically necessary only under specific, documented circumstances that demonstrate functional impairment. Coverage may be granted if the milia are actively growing, causing chronic irritation, becoming painful, or showing signs of infection. In these cases, the lesions are considered symptomatic medical issues requiring intervention.
Functional impairment includes milia near the eye that causes visual obstruction or significant irritation of the eyelid or cornea. Milia may also interfere with a medical device, such as forming under the seal of a continuous positive airway pressure (CPAP) mask, preventing an airtight fit. To justify the claim, the dermatologist must use the appropriate diagnostic code, such as ICD-10 code L72.0, and documentation detailing the specific medical reason for removal.
Costs and Financial Responsibilities
When milia removal is deemed cosmetic, the patient is responsible for the full out-of-pocket cost, which varies widely based on location and the number of lesions. A new patient consultation with a dermatologist typically costs between $150 and $300 without insurance. The removal itself is often billed on a per-lesion or per-session basis.
For manual extraction, some clinics may charge around $75 for the first lesion and an additional $25 for each subsequent lesion. Other methods, such as electrodessication, can cost approximately $150 for a single spot or start at $125 to $300 per session. If a patient is uninsured or not using insurance, federal law requires providers to offer a “Good Faith Estimate” detailing the expected cost of the procedure before it is performed.
If a claim is submitted and subsequently denied as cosmetic, patients have the right to appeal the decision. This process involves gathering additional medical records that emphasize the functional or symptomatic nature of the lesions, such as photographic evidence of inflammation or a detailed statement from the dermatologist linking the milia to an ongoing health issue. However, many patients opt to pay the out-of-pocket fee to avoid the lengthy appeal process for what is often a low-cost, minor procedure.