Milia are small, dome-shaped white or yellowish bumps that form on the skin, and their removal is frequently classified as an aesthetic procedure. Health insurance is designed to cover medically necessary treatments, meaning the decision to pay for milia removal hinges on whether a dermatologist can successfully prove the procedure is required for health rather than cosmetic reasons. Coverage depends entirely on the context of the procedure, and the question of whether insurance covers milia removal does not have a simple yes or no answer.
Milia: Definition and Removal Methods
Milia are tiny cysts that develop when keratin, a strong protein found in skin tissues, hair, and nail cells, becomes trapped beneath the skin’s surface. These small bumps, typically measuring 1 to 3 millimeters, are not a form of acne and are non-inflammatory, meaning they rarely cause redness or swelling. While they commonly appear on the face, especially around the eyes, cheeks, and nose, they can occur anywhere on the body.
In adults, milia often persist longer than in infants and may be associated with skin trauma, long-term sun damage, or the use of heavy creams. Professional removal methods are generally simple, in-office procedures with minimal downtime. The most common technique is deroofing or extraction, where a dermatologist uses a sterile needle or micro-lance to create a tiny opening and gently remove the keratin plug.
Other professional options include cryotherapy (using liquid nitrogen to freeze the cysts) or laser ablation. Topical retinoids or chemical peels containing ingredients like salicylic acid may also be used to encourage skin exfoliation and help clear the milia over time.
The Deciding Factor: Medical Necessity vs. Aesthetic Treatment
Insurance companies use the concept of “medical necessity” as the primary factor for coverage in milia removal decisions. A procedure is considered medically necessary if it is required to diagnose, treat, prevent, or alleviate symptoms that interfere with daily functioning. Because milia are benign and harmless, their removal is overwhelmingly classified as a cosmetic procedure, which insurers do not cover.
To shift the procedure from cosmetic to medical, a patient must present with documented evidence that the milia are causing a genuine medical problem. This could involve chronic irritation from clothing or rubbing that leads to documented inflammation or secondary infection. Milia that significantly interfere with a patient’s vision or function, such as those near the eyelid margin that rub against the cornea, may also meet the medical necessity threshold.
The dermatologist must document the medical justification in the patient’s chart, often including photos and notes detailing the functional impairment. Without documentation of physical symptoms, such as pain, bleeding, or interference with a bodily function, the insurance claim will likely be denied. Providers are strict about adhering to these requirements, as billing insurance for a purely cosmetic procedure is considered fraudulent.
Navigating Pre-Authorization and Denial Appeals
Once a medical justification is established, the next administrative hurdle is often pre-authorization. This is a process where the healthcare provider must obtain approval from the insurance company before performing the removal procedure. The provider’s office submits documentation, including the reasons for medical necessity and the Current Procedural Terminology (CPT) code that identifies the procedure as medical rather than cosmetic.
Using the correct medical coding is essential, as a cosmetic code will result in an immediate denial. Insurance companies typically respond to these requests within a few weeks; receiving approval upfront ensures the procedure is covered, though the patient remains responsible for deductibles or copays. If the insurance company denies the initial request for pre-authorization, the patient has the right to appeal the decision.
The appeal process involves the patient and the physician submitting additional clinical documentation, which might include a letter of medical necessity detailing why other, less costly treatments have failed. Patients who appeal a denial often succeed in gaining coverage, so a rejection should not be considered the final word. Navigating this process requires persistence and close communication between the patient, the dermatologist’s office, and the insurance provider.