Concise Purpose: To evaluate whether the criteria used by ...



Reduction Mammaplasty: A Review of Managed Care Medical Policy Coverage Criteria

Jesse T. Nguyen, B.S., Michael J. Wheatley, M.D., Paul L. Schnur, M.D., F.A.C.S., Tuan A. Nguyen, M.D., D.D.S., F.A.C.S., Shelley R. Winn, Ph.D.

INTRODUCTION: Symptomatic macromastia is a significant health problem, with 125,614 breast reductions performed in 2004. Increasingly, insurance companies are denying coverage for this procedure based on company medical policies. These policies are ostensibly intended to distinguish cosmetic from medically necessary reductions. The correlation of insurance company criteria to the scientifically established indications for reduction mammoplasty has never been studied. We undertook a review of insurance company medical policies for reduction mammoplasty to determine whether the criteria upon which insurance coverage determinations are made are consistent with published data regarding the indications for this procedure.

METHOD: We reviewed the medical literature on reduction mammoplasty and identified what conclusions can reasonably be drawn from this literature on the common insurance criteria used to determine medical necessity for reduction mammoplasty. Conclusions based on the medical literature regarding volume of reduction, symptom presentation, conservative therapy, obesity, presence of bra strap grooving and intertrigo, age at time of reduction were formulated, and these conclusions were compared to the criteria of 87 different health insurance reduction mammoplasty medical policies.

RESULTS: We were unable to identify any medical policies that could be supported in entirety by the medical literature and many that are completely unfounded based on the medical literature. Insurance company medical policy requirements with respect to reduction mammoplasty are, in many cases, arbitrary and without scientific basis. Requirements for a specific volume of reduction, a minimum age, a maximum body weight and a trial of conservative therapy are required by the majority of managed care medical policies, even though scientific support for any of these requirements is not evident in the medical literature.

CONCLUSION: Insurance coverage for reduction mammoplasty seems frustratingly arbitrary to most plastic surgeons. Our findings confirm that the criteria used by insurers to determine coverage for reduction mammoplasty are, for the most part, arbitrary and without relevance to the published studies on the indications for this procedure. Many women who will benefit from reduction mammoplasty are inappropriately denied care due to these invalid guidelines. We hope that exposure of this practice will promote more equitable insurance coverage guidelines for reduction mammoplasty.

REFERENCE

1. Kerrigan CL, Collins ED, Kim HM, Schnur PL, Wilkins E, Cunningham B, Lowery J. Reduction mammoplasty: defining medical necessity. Med Decis Making 22:208-17,2002.

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