Skin cancer screening typically involves a visual examination of the entire body by a dermatologist to identify suspicious moles or growths. Skin cancer is the most common cancer, with over five million cases diagnosed annually in the U.S. Early detection significantly improves outcomes, as localized melanoma has a five-year survival rate exceeding 99%. Coverage is determined by the type of service—preventive or diagnostic—which is a common concern for many older adults.
The Distinction: Screening Versus Diagnosis
Medicare Part B generally does not cover routine, full-body skin cancer screenings when performed as a preventive service. The program’s framework does not include these checks in its list of covered preventive benefits, unlike certain other screenings. If an individual schedules an appointment solely for a precautionary visual check without a specific concern, they will likely be responsible for the entire cost of the visit.
The difference in coverage hinges on the concept of medical necessity, which dictates whether a visit is billed as a preventive screening or a diagnostic evaluation. A visit becomes covered under Part B if it is considered diagnostic, meaning the doctor is examining a specific problem or symptom. For example, if a patient reports a mole on their arm that has recently changed shape or color, the dermatologist’s visit is now considered a diagnostic evaluation.
In this diagnostic scenario, the healthcare provider documents the specific concern—such as a “changing mole on the arm”—which provides the medical justification for Medicare Part B coverage. Even if a patient comes in for an unrelated issue and the physician notices a suspicious lesion, the subsequent evaluation of that lesion is covered. Dermatologists, as specialists, primarily bill using Evaluation and Management codes for medical evaluations, rather than the preventive codes intended for primary care providers.
Specific Coverage Under Medicare Part B
When a dermatology visit is deemed medically necessary for a diagnostic evaluation, it falls under the coverage rules of Medicare Part B. Part B covers outpatient services, including doctor visits and diagnostic tests. However, coverage does not mean the service is free, as beneficiaries must share in the cost.
The patient is first responsible for the annual Part B deductible, which must be met before coverage begins. Once the deductible is satisfied, the patient is responsible for 20% of the Medicare-approved amount for the diagnostic visit and any associated services. Medicare covers the remaining 80% of the approved cost.
A skin check performed by a primary care physician during an Annual Wellness Visit is covered, as the discussion of health risks and preventive care is part of the benefit. However, this check is not a full-body examination by a specialist, and any referral to a dermatologist would revert to the diagnostic rules requiring a specific concern to be covered. If the dermatologist does not accept Medicare’s approved payment rate, the patient may also face additional excess charges.
How Medicare Advantage Changes Coverage
Medicare Advantage plans are offered by private insurance companies approved by Medicare. These plans must provide all the coverage offered by Original Medicare Part A and Part B, but they frequently offer additional benefits. This is where the coverage landscape for routine screenings changes significantly.
Many Medicare Advantage plans include coverage for routine, preventive annual skin cancer screenings as a supplemental benefit. These plans use these added benefits to attract members, offering a service that Original Medicare generally excludes. An individual enrolled in a Part C plan might be able to get a full-body skin check without requiring a suspicious lesion.
Because these supplemental benefits vary widely, a person should consult their specific plan documents, the Summary of Benefits, or contact their plan provider directly. The out-of-pocket costs, such as co-pays or co-insurance, for these extra screenings also depend on the individual plan’s structure. In many cases, a referral from a primary care physician may be required before seeing a dermatologist under a Medicare Advantage plan.
Coverage for Follow-Up Procedures
If a dermatologist finds a suspicious area during a covered diagnostic visit, the subsequent medical procedures are also covered under Medicare Part B. This includes the removal of a small sample for laboratory analysis, known as a biopsy. The removal of precancerous lesions, such as actinic keratoses, through methods like cryosurgery or topical chemotherapy, is also covered as treatment.
Should the biopsy confirm a cancer diagnosis, the subsequent treatment procedures are covered. This includes surgical removal of the cancerous tissue (excision) and specialized techniques like Mohs surgery. Mohs surgery, a precise layer-by-layer removal method, is covered under Part B for skin cancer treatment.
For these follow-up procedures, the standard cost-sharing rules for Part B apply. After the patient has met their annual deductible, they will pay 20% of the Medicare-approved amount for the biopsy, excision, or Mohs surgery.