The complex insurance reimbursement landscape in reduction mammaplasty: how does the American plastic surgeon navigate it?

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.