An Overview Of U.S. Insurance Coverage Of Reduction Mammaplasty
Catherine Rawes, MB ChB1, Ledibabari M. Ngaage, MB BChir2, Mimi R. Borrelli, MBBS MSc3, Joseph Puthumana, BS2, Sheri Slezak, MD2, Yvonne M. Rasko, MD2.
1Yorkshire and Humber Foundation School, Leeds, United Kingdom, 2University of Maryland Medical Center, Baltimore, MD, USA, 3Stanford University School of Medicine, Palo Alto, CA, USA.
Reduction mammaplasty leads to long-lasting relief of symptoms of macromastia. Insurance companies act as gatekeepers to accessing healthcare by determining the medical necessity of surgical procedures, such as reduction mammaplasty. We sought to evaluate insurance coverage and policy criteria for reduction mammaplasty.
We conducted a cross-sectional analysis of United States insurance policies on reduction mammaplasty. Insurance providers were selected based on their enrolment data and market share. We conducted telephone interviews and web-based searches to identify the policies. Medical necessity criteria and reasons for denial were abstracted from the publicly available policies that offered coverage.
We reviewed 63 insurers, one in ten did not hold an established policy for reduction mammaplasty. Of the 48 publicly available policies, shoulder pain and backache were the most common symptoms required for preapproval (98% and 98%, Figure 1). Multiple forms of preoperative imaging were required: photographs (46%), x-ray evidence of kyphosis (38%), and mammography (35%). A minimum resection volume was requested by 88% of policies. One third offered a choice between the removal of a minimum weight per breast or a volume based on body surface area (BSA) (31%). However, over half of the companies (54%) utilised BSA calculations to predict minimum resection volume. Medical necessity criteria that extended beyond national recommendations included: trial of weight loss (23%) and nipple position (10%). Reasons for coverage exclusion included: to improve appearance or correct asymmetry (38%), psychological distress (27%), poor clothing fit (19%), nipple-areolar distortion (17%), and pendulous breasts (17%).
Insurance policy criteria for reduction mammaplasty are discordant with current national recommendations and current clinical evidence. Many policies still cling to outdated minimum resection of tissue criteria which have been proven to be not correlated to symptom relief and limits access to reduction mammaplasty. We propose a comprehensive guideline to maximise coverage of reduction mammaplasty. Further research is required to provide a stronger evidence base for the current preapproval criteria in use.
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