Medicare, the federal health insurance program for people aged 65 or older and certain younger individuals with disabilities, is often asked to cover the removal of warts (verrucae). Coverage depends entirely on the clinical context of the patient’s condition. While Medicare covers necessary medical care, it excludes cosmetic procedures. Therefore, coverage hinges on documentation from a healthcare provider establishing that the procedure treats a specific medical problem, not just an aesthetic preference.
Criteria for Coverage: Medical Necessity
Medicare covers wart removal only when the procedure is classified as medically necessary to treat a health condition, not simply to improve appearance. This requirement is rooted in National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) established by regional Medicare contractors. These guidelines define the specific clinical circumstances under which a wart warrants covered removal.
Removal is deemed necessary if the wart is causing immediate symptoms or poses a risk to the patient’s health or function. Examples of medical necessity include chronic bleeding, persistent pain, or signs of inflammation and infection (such as pus or swelling). A physician may also classify removal as necessary if the wart is growing rapidly, changing in appearance, or if a biopsy is required to rule out malignancy.
The physical location and behavior of the wart are important factors in determining coverage. For example, a plantar wart that impedes walking or a wart near the eye that obstructs vision generally meets the criteria for necessary treatment. If a wart is actively spreading, especially in an immunocompromised patient, its removal is often covered to prevent further dissemination of the human papillomavirus (HPV).
How Medicare Part B Handles Removal Procedures
Wart removal coverage falls primarily under Medicare Part B, which pays for outpatient services from physicians and other healthcare providers. Part B covers the costs associated with the procedure, including the professional fee and the use of the office or clinic setting. The removal must be performed by an approved provider, such as a dermatologist, podiatrist, or general physician, in an approved outpatient environment.
Common removal methods include cryotherapy (freezing the wart with liquid nitrogen), electrosurgery, surgical excision, and laser ablation techniques. These are covered when medical necessity is established. The provider must select the appropriate Current Procedural Terminology (CPT) code for the procedure and link it to a diagnostic code (ICD-10) that documents the medical reason for the removal.
This documentation demonstrates that the treatment addresses a covered medical condition, such as pain or infection, rather than a cosmetic concern. If covered, payment is made to the provider under the Part B fee schedule, recognizing the service as an outpatient surgical intervention. If a high-strength prescription medication is used for treatment, coverage for that drug is typically handled under the patient’s Medicare Part D or Medicare Advantage plan with drug coverage.
Patient Financial Responsibility and Cosmetic Exclusions
Even when wart removal is deemed medically necessary and covered by Medicare Part B, the beneficiary retains financial responsibilities. After meeting the annual Part B deductible, the patient is responsible for a 20% coinsurance of the Medicare-approved amount. This cost applies to the physician’s service and any associated facility fees for the outpatient visit.
Patients enrolled in a Medicare Advantage Plan (Part C) or a Medigap policy may have different cost-sharing arrangements. Medicare Advantage plans replace Original Medicare and must cover the same services, but they structure costs differently, often using copayments instead of coinsurance. Medigap plans help pay the 20% coinsurance and the Part B deductible, potentially reducing the patient’s financial burden.
If removal is determined to be purely for aesthetic reasons, Medicare will not provide payment, as it is not medically necessary. In such cases, the procedure is considered a cosmetic exclusion, and the patient is responsible for 100% of the cost. Providers are typically required to inform the patient in advance that Medicare will not cover the procedure and that the patient will be liable for the full charge.