A Review of National Insurance Coverage of Post-bariatric Upper Body Lift

The financial toxicity of postbariatric body contouring surgery: a survey study of an urban tertiary care center's patients

BACKGROUND

Patients with obesity who undergo bariatric surgery achieve sustained weight loss but are often left with excess skin folds that cause functional and psychological deficits. To remove excess skin, patients can undergo postbariatric BCS; however, cost and lack of insurance coverage present a significant barrier for many patients.

OBJECTIVES

This study aimed to characterize the financial impact of treatment on all patients who received bariatric surgery and to compare between those receiving only bariatric surgery and those with postbariatric BCS.

SETTING

Email-based survey study at an urban tertiary care center.

METHODS

Surveys that included the COST-FACIT were sent to patients with a history of bariatric surgery and/or post-bariatric BCS.

RESULTS

One hundred and five respondents completed the survey, of which 19 reported having postbariatric BCS. Patients with postbariatric BCS had slightly higher COST scores than those receiving bariatric surgery only, but this difference was not significant (15.6 versus 17.8, P = .23). Most patients (76%) did not have an awareness of BCS or BCS cost prior to bariatric surgery, and many (68%) had more loose skin than anticipated.

CONCLUSIONS

Financial toxicity was similar across all postbariatric surgery patients surveyed regardless of history of BCS. However, survey respondents noted a gap between patient education and expectations around loose skin and body contouring that can be addressed through improved presurgical counseling.

A National Analysis of Socioeconomic Variables of Access to Inpatient Body Contouring Procedures After Bariatric Surgery

BACKGROUND

Weight loss following bariatric surgery often results in excess skin, which has led to a population of patients seeking body contouring surgery (BCS). This study aimed to investigate the prevalence of patients who underwent BCS following bariatric surgery using the national inpatient sample (NIS) database and to assess the demographic and socioeconomic variables of this cohort.

METHODS

NIS database was queried from 2016 to 2019 using ICD-10 codes to identify patients that underwent bariatric surgery procedures. Patients who subsequently underwent BCS were compared to those who did not. Multivariate logistic regression was used to identify factors associated with receipt of BCS.

RESULTS

A total of 263,481 patients that underwent bariatric surgery were identified. Of those, 1777 (0.76%) patients underwent subsequent inpatient BCS. Being female was associated with greater odds of undergoing body contouring (OR 1.28 95% CI 1.13-1.46, p = 0.0001). Patients who underwent BCS were more likely to have their procedure performed in large and government-controlled hospitals than bariatric surgery-only patients (55% vs. 50%, p < 0.0001, and 11% vs. 9.4%, respectively). Higher-income did not impose higher odds of receiving BCS compared to lowest income quartile (OR 0.99, 95% CI 0.86-1.16, p = 0.99066). Lastly, compared to Medicare holders, self-payers (OR 3.5, 95% CI 2.83-4.30, p < 0.0001) or private insurance (OR 1.23, 95% CI 1.09-1.40, p = 0.001) had greater odds of undergoing BCS.

CONCLUSIONS

There is a gap in access to BCS procedures, with cost and insurance coverage being the principal barriers. Developing policies that allow for holistic evaluation of patients is crucial to improve access to these procedures.

Sociodemographic characteristics of patients and their use of post-bariatric contouring surgery in the US

BACKGROUND

Expansion of healthcare insurance coverage to bariatric surgeries has led to an increased demand from patients for post-bariatric contouring surgeries. This study examined the relationship between the use of contouring procedures on post-bariatric surgery patients, clinical need and sociodemographic factors.

METHODS

Data were extracted from the Healthcare Cost and Utilization Project (HCUP) Nationwide Ambulatory Surgery Sample (NASS) regarding hospital-owned ambulatory surgical centres in the US. Episodes without missing values relating to patients, 18 years old or above were the primary unit of analysis. Episodes were excluded if the field regarding expected payer was reported as "no charge." The primary outcome was the likelihood of panniculectomy, abdominoplasty, and mastopexy among post-bariatric surgery patients; and the degree to which uptake of these types of contouring surgery were associated with age, gender, median households' income, expected payer, patient's location, and comorbidity.

RESULTS

A total of 66,368 weighted episodes of care received by patients who had had bariatric surgery were extracted (54,684 female [82.4%]; mean age, 51.3 [SD, 12.1]; 6219 episodes had contouring surgeries [9.37%]). Panniculectomy was the most common post-bariatric contouring procedure (3.68%). Uptake of post-bariatric contouring procedures was associated with age, sex, payment type, area-based measures of median household income, and patient location. Compared to Medicare insured patients, the odds of receiving contouring surgery among self-payers were 1.82 (95% CI, 1.47 to 2.26) for panniculectomy, 14.79 (95% CI, 12.19 to 17.93) for abdominoplasty and 47.97 (95% CI, 32.76 to 70.24) for mastopexy. Rank order of comorbidity profiles also differed between insured and self-paying recipients of contouring surgery.

CONCLUSIONS

Insurance status of bariatric surgery patients and their sex were strongly associated with receipt of a range of contouring procedures. Self-payments were associated with a doubling of the odds of having panniculectomy and an increase in the odds to approximately 14 times for abdominoplasty and 48 times for mastopexy. Thus, access to contouring surgery by post-bariatric patients may be disproportionately dependent on personal preference supported by ability to pay rather than clinical need. Further research is needed to examine the impact of contouring or delayed/denied contouring on health status.

Gender-Affirming Health Insurance Reform in the United States

INTRODUCTION

In May 2014, the US Department of Health and Human Services prohibited insurance discrimination of transgender individuals. Despite this, insurance plans often lack explicit guidelines on gender transition-related care and coverage of surgical procedures is extremely varied. We evaluated the evolution of insurance coverage of gender-affirming care following the 2014 legislative change.

METHODS

Insurance providers were selected based on company market share. We conducted a Web-based search and telephone interviews to identify the corresponding policies related to gender-affirming health care. We compared policy changes made before and after the 2014 US Department of Health and Human Services decision.

RESULTS

Of the 92 insurers surveyed, 7% did not have a policy, and 315 policy revisions were documented. After the legislation, a significantly higher proportion of policy revisions were related to coverage of services (36% vs 11%, P < 0.0001), removal of existing criteria significantly decreased (23% vs 49%, P = 0.0044), and addition of criteria unrelated to international standards sharply increased (32% vs 2%, P = 0.0002). This resulted in reduced coverage of facial feminization, hair transplantation, laryngochondroplasty, and voice modification surgery. However, nipple reconstruction experienced increased coverage. The percentage of revisions to add preauthorization criteria to meet international standards (49% vs 45%, P = 0.6714) or to change terminology (37% vs 27%, P = 0.1055) were similar before and after the legislation.

CONCLUSIONS

After the transformative legislation in 2014, an increasing number of insurance companies established gender transition-related policies. As more patients seek gender-affirming care, insurers deviate from international guidelines and create additional benchmarks that may act as barriers to care.

A Cross-Sectional Analysis of American Insurance Coverage of Prominauris Otoplasty

BACKGROUND

Prominent ears affect up to 5% of the population and can lead to social and psychological concerns at a critical time of social development. It can be addressed with an otoplasty, which is often considered a cosmetic procedure. The authors assessed insurance coverage of all indications of otoplasty and their medical necessity criteria.

METHODS

A cross-sectional analysis was conducted of 58 insurance policies for otoplasty. The insurance companies were selected based on their state enrolment and market share. A web-based search and telephone interviews were utilized to identify the policies. Medically necessary criteria were then abstracted from the publicly available policies.

RESULTS

Of the 58 insurance policies assessed, 25 (43%) provide coverage of otoplasty. There were 2 indications for coverage: hearing loss (n = 20, 80%) and normal approximation (n = 14, 56%), which would encompass prominent ears. Normal approximation was a covered indication for significantly fewer insurers than hearing loss (56% versus 80%, P = 0.0013). Of all the otoplasty policies which covered normal approximation, 21% (n = 3) addressed protruding ears as an etiology. Prominent ears were not included in any policies which covered hearing loss. All policies inclusive of prominent ears required a protrusion of >20 mm from the temporal surface of the head (n = 3, 100%).

CONCLUSIONS

There is a great discrepancy in insurance coverage of otoplasty. A greater proportion of policies cover hearing loss compared to normal approximation. The authors encourage plastic surgeons to advocate for the necessity and coverage of normal approximation by insurers.

The PRS Rainbow Classification for Assessing Postbariatric Contour Deformities

Supplemental Digital Content is available in the text.

Background:

There is a need for a reliable classification system to grade contour deformities and to inform reimbursement of body contouring surgery after massive weight loss. We developed the PRS Rainbow Classification, which uses select photographs to provide standardized references for evaluating patient photographs, to classify contour deformities in postbariatric patients. To assess the reliability of the PRS Rainbow Classification to classify contour deformities in massive weight loss patients.

Methods:

Ten independent experienced plastic surgeons, 7 experienced medical advisors of the healthcare insurance company, and 10 laypersons evaluated 50 photographs per anatomical region (arms, breast, abdomen, and medial thighs). Each participant rated the patient photographs on a scale of 1–3 in an online survey. The inter-observer and the intra-observer reliabilities were determined using intra-class correlation coefficients (ICCs). The ICC analyses were performed for each anatomical region.

Results:

Inter-observer reliability was moderate to good in the body regions “arms,” “abdomen,” “medial thighs,” with mean ICC values of 0.678 [95% confidence interval (CI), 0.591–0.768], 0.685 (95% CI, 0.599–0.773), and 0.658 (95% CI, 0.569–0.751), respectively. Inter-observer reliability was comparable within the 3 different professional groups. Intra-observer reliability (test–retest reliability) was moderate to good, with a mean overall ICC value of 0.723 (95% CI, 0.572–0.874) for all groups and all 4 body regions.

Conclusions:

The moderate to good reliability found in this study validates the use of the PRS Rainbow Classification as a reproducible and reliable classification system to assess contour deformities after massive weight loss. It holds promise as a key part of instruments to classify body contour deformities and to assess reimbursement of body contouring surgery.