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The Complex Insurance Reimbursement Landscape in Reduction Mammaplasty: How Does the American Plastic Surgeon Navigate It?

Frey, Jordan D. MD*; Koltz, Peter F. MD; Bell, Derek E. MD; Langstein, Howard N. MD

doi: 10.1097/01.SAP.0000435778.81934.cd
Breast Surgery
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Background Reduction mammaplasty (RM) is generally thought of as a reconstructive procedure, frequently but variably reimbursed by third-party payers. The purpose of this study was to assess US plastic surgeons’ opinions of and interactions with the insurance coverage environment surrounding the reimbursement of RM.

Methods The RM policies of 15 regional and nationwide health insurance carriers were analyzed. A survey regarding RM was distributed to all members of the American Society of Plastic Surgeons and subsequently analyzed.

Results Most insurance carriers require a minimum resection weight, a minimum age, and a conservative therapy trial. A total of 757 surgeons responded to our survey. Seventy-six percent of the respondents believe that only some RM procedures should be covered by insurance. Sixty-four percent feel that symptoms are the most important factor in the surgeon’s determination of medical necessity. Fifty-seven percent state that a breast resection weight of 500 g or greater is required for coverage in their region. Seventy-one percent believe that this weight should be less than 500 g per breast. If the surgeon estimates that he/she will remove 500 g per breast, the minimum weight for coverage, 61% of the surgeons would have patients sign a statement of liability for payment. If the intraoperative resection weight is inadequate, 45.6% would not remove additional tissue, risking nonpayment; 32.7% would complete the procedure and inform the patient that payment is out-of-pocket.

Conclusions Insurance reimbursement for RM varies in approval by carrier. Surgeons believe that signs and symptoms of macromastia determine medical necessity, whereas insurance carriers place a larger emphasis on resection weights.

From the *Institute of Reconstructive Plastic Surgery, Department of Plastic Surgery, NYU Langone Medical Center; †Division of Plastic Surgery, University of Rochester Medical Center, Rochester, NY.

Received June 13, 2013, and accepted for publication, after revision, September 6, 2013.

Conflicts of interest and sources of funding: none declared.

Reprints: Howard N. Langstein, MD, Division of Plastic Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642. E-mail: Howard_Langstein@URMC.Rochester.edu.

© 2014 by Lippincott Williams & Wilkins