Navigating the Insurance Landscape for Coverage of Reduction Mammaplasty

Reimbursement policies of Swiss health insurances for the surgical treatment of symptomatic breast hypertrophy: a retrospective cohort study

BACKGROUND

Patients with symptomatic breast hypertrophy typically suffer from chronic back pain, recurrent skin irritation at the inframammary fold and/or low self-esteem resulting in impaired quality of life. Reduction mammaplasty has been shown to effectively treat symptomatic breast hypertrophy with high patient satisfaction. Despite the obvious benefits, reimbursement requests for reduction mammaplasty are initially often refused by the patient's health insurance company, thereby frequently resulting in additional examinations and eventually extra expenses. The study aim was to evaluate the reimbursement policy by health insurance companies for treatment costs of reduction mammaplasty in a patient cohort, to quantify the generation of additional costs due to initial refusal of reimbursement, as well as to assess back pain after surgical treatment.

METHODS

A retrospective cohort study was conducted in two Swiss centres. Inclusion criteria were a diagnosis of symptomatic breast hypertrophy, cost approval for reduction mammaplasty by the health insurance between October 2014 and March 2021 and informed consent for the study. The exclusion criteria were private payers for reduction mammaplasty and patients aged below 18. Primary outcome measures included median duration between the first request for reimbursement sent to the health insurance and the receipt of its approval, the number of requests needed per patient, as well as the number and type of additional outpatient visits conducted by specialists other than plastic surgeons, including the need for further diagnostic investigations and therapeutic measures. Secondary outcome measures included the additional costs generated in patients with more than one request. Finally, back pain after surgical treatment was assessed using a visual analogue scale (VAS).

RESULTS

 A total of 46 patients with symptomatic breast hypertrophy and approval for reimbursement were included in the study. The median duration to obtain cost approval for reduction mammaplasty was 9.4 weeks (ranging from 1 to 154 weeks). Reimbursement was approved after 1, 2, 3 or 4 requests in 26, 6, 11 and 3 patients, respectively. If the first request was refused, further clinical evaluation by specialists, additional imaging of the cervical spine and physiotherapy was necessary in 70%, 35% and 80% of the patients, respectively. A patient requiring more than one request to obtain cost approval for reduction mammaplasty generated additional mean costs of approximately 2400 CHF, i.e. 2181 CHF, 164 CHF and 46 CHF for ongoing physiotherapy, additional outpatient visit by a specialist doctor and complementary imaging compared to patients needing only one request for cost approval. The level of back pain could be reduced from 7.0 before surgery to 1.6 after surgery.

CONCLUSION

 Patients with symptomatic breast hypertrophy who needed more than one request for cost approval (43%) had to undergo further outpatient visits and/or radiological examinations, as well as physiotherapy, despite a clear indication for surgery, resulting in a prolonged symptomatology and increasing healthcare costs.

Evaluation of the Impact of Physical Therapy on Patients With Macromastia Seeking Breast Reduction Surgery

BACKGROUND

Macromastia significantly impairs females' quality of life, with treatments such as physical therapy (PT) often providing only temporary relief. Insurance routinely denies breast reduction surgery, despite little relief after conservative treatments. Research on the efficacy of PT for macromastia is limited.

OBJECTIVES

In this study, we investigated the efficacy of PT for macromastia and identified patient factors associated with progression to surgery.

METHODS

We conducted a retrospective cohort study of patients with macromastia between 2017 and 2021. We collected data on presenting symptoms, attempted conservative treatments, PT duration, and whether surgery was performed. All patients were invited to participate in a survey regarding their symptoms, treatments, and responses to treatments. Symptoms associated with patients progressing to a breast reduction were evaluated with a multiple logistic regression.

RESULTS

Among the 327 patients identified with macromastia, 312 (95.41%) reported back pain and 272 (83.18%) attempted PT. Of the 72 (22.02%) patients who responded to the survey, 152 (46.48%) underwent subsequent surgery. The mean time from initial consultation to surgery was 283 days. Bra strap grooving was associated with progression to surgery (odds ratio = 1.90, CI = 1.02-3.54). Mean patient-reported pain levels decreased after surgery compared to after PT (pre-PT = 7.1, post-PT = 7.1, post-surgery = 3.1, P < .001).

CONCLUSIONS

Patients frequently undergo PT before breast reduction surgery despite no significant reduction in pain, whereas those who undergo surgery experience permanent relief and significantly reduced pain. Patients with bra strap grooving are more likely to progress to surgery. The requirement for PT as a prerequisite for surgery by insurance companies should be reevaluated.

LEVEL OF EVIDENCE: 3

Predicting Reduction Mammaplasty Total Resection Weight With Machine Learning

BACKGROUND

Machine learning (ML) is a form of artificial intelligence that has been used to create better predictive models in medicine. Using ML algorithms, we sought to create a predictive model for breast resection weight based on anthropometric measurements.

METHODS

We analyzed 237 patients (474 individual breasts) who underwent reduction mammoplasty at our institution. Anthropometric variables included body surface area (BSA), body mass index, sternal notch-to-nipple (SN-N), and nipple-to-inframammary fold values. Four different ML algorithms (linear regression, ridge regression, support vector regression, and random forest regression) either including or excluding the Schnur Scale prediction for the same data were trained and tested on their ability to recognize the relationship between the anthropometric variables and total resection weights. Resection weight prediction accuracy for each model and the Schnur scale alone were evaluated based on using mean absolute error (MAE).

RESULTS

In our cohort, mean age was 40.36 years. Most patients (71.61%) were African American. Mean BSA was 2.0 m 2 , mean body mass index was 33.045 kg/m 2 , mean SN-N was 35.0 cm, and mean nipple-to-inframammary fold was 16.0 cm. Mean SN-N was found to have the greatest variable importance. All 4 models made resection weight predictions with MAE lower than that of the Schnur Scale alone in both the training and testing datasets. Overall, the random forest regression model without Schnur scale weight had the lowest MAE at 186.20.

CONCLUSION

Our ML resection weight prediction model represents an accurate and promising alternative to the Schnur Scale in the setting of reduction mammaplasty consultations.

National Legislative Favorability and Insurance Coverage for Adult and Adolescent Gender-Affirming Surgery

BACKGROUND

Despite established medical necessity, laws prohibiting coverage discrimination, and increasing numbers of transgender and gender-diverse patients seeking gender-affirming surgery (GAS), cost and restrictive insurance policies continue to be the most common barriers. As recent legislation places further restrictions on GAS, this study aimed to provide an updated review of insurance policies and assess the relationship between legislative favorability and coverage.

METHODS

Insurance policies of groups representing 80% market coverage in each state were collected for gender-affirming chest, genital, and facial surgery. Policies were categorized based on previously published methodologies: never-covered, case-by-case, and preauthorization. The relationship between established scores of legislative favorability and policy coverage in each state was analyzed and compared across regions.

RESULTS

Of the 316 analyzed policies, coverage was preauthorized most often for genital (94.0%), masculinizing top (93%), feminizing top (74%), and facial reconstruction (24%). Higher legislative scores in the Northeast and West, and individual states were predictive of increased genital, facial, and all forms of adolescent GAS, but were not correlated to chest GAS.

CONCLUSIONS

Compared with previous studies, our findings suggest that there is a growing acceptance of GAS as medically necessary. However, the correlation between legislative scores and genital, face, and adolescent GAS coverage may suggest increased reliance on sociopolitical factors for access in the absence of comprehensive medical guidelines, which are more established for chest reconstruction. Significantly higher coverage of masculinizing versus feminizing chest surgery suggests additional burden of proof for GAS with a cosmetic overlap.

Readability of Online Materials in Spanish and English for Breast Reduction Insurance Coverage

INTRODUCTION

Breast reduction surgery aims to alleviate physical discomfort and improve the quality of life for individuals with macromastia. Insurance coverage plays a crucial role in making this surgery accessible, but navigating the complex approval process can be challenging. Online resources have become a primary information source, but limited research exists on the adequacy of online materials, particularly for Spanish-speaking patients. This study evaluates the readability, actionability, and understandability of online educational materials on breast reduction insurance coverage for Spanish- and English-speaking patients.

METHODS

We conducted an online search using the phrase "breast reduction insurance" and selected the first eight institutional or organizational websites that provided information on breast reduction insurance in both English and Spanish. We evaluated online materials using the Patient Education and Materials Assessment Tool (PEMAT), Cultural Sensitivity Assessment Tool (CSAT), and Simplified Measure of Gobbledygook, Spanish (SOL). These tools were used to assess factors such as understandability and actionability, cultural sensitivity, and readability of the materials.

RESULTS

Both English and Spanish materials scored high in understandability and actionability, with similar average scores between the languages. Cultural sensitivity scores indicated acceptable materials. However, Spanish materials had a higher reading grade level and more hard words compared to English materials.

CONCLUSION

There is a need for accessible and understandable online resources on breast reduction insurance coverage, particularly for Spanish-speaking patients. While the assessed websites generally provided comprehensible information, improvements can be made to enhance visual aids and simplify language. These improvements can better educate patients, improve outcomes, and reduce healthcare costs.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Preauthorization Inconsistencies Prevail in Reduction Mammaplasty

Background

Despite evidence documenting the physical and psychological benefits of breast reduction, third-party payer approval remains a cumbersome process. The objective of this study was to assess differences in medical necessity criteria for reduction mammaplasty among US insurance carriers while analyzing trends in claim denials and appeals.

Methods

The medical necessity criteria for reduction mammaplasty were retrieved from seven large health insurance carriers. Data were extracted from each policy, including claim requirements for approval. Additionally, prospective data on claims and denials submitted from January through August 2022 were collected from The Auctus Group, a medical consulting firm.

Results

All the policies have been updated since January 2020. Five of the seven policies specifically listed what documentation was required for preauthorization approval, with five third-party payers requiring photograph documentation. Policies required documentation of one to three symptoms lasting from 6 weeks to 1 year. All companies reported a tissue resection estimate threshold, but cutoffs varied. Of 380 reduction mammaplasties performed, 158 (41.6%) received a denial on initial insurance submission. Considering appeals, a total of 216 denials were reviewed with an average of 1.37 denials per patient. Of the 158 initial denials, 104 (65.8%) of these were from claims that received preauthorization. In 12 cases, third-party payers stated that no prior authorization was necessary yet still denied the claim.

Conclusions

Wide variability exists in medical necessity criteria for reduction mammaplasty policies among major insurance carriers. These nuances introduce inefficiencies for practices contributing to high denial and appeal rates while delaying surgical care for patients.

Macromastia and Reduction Mammaplasty: Analysis of Outpatient Cost of Care and Opioid Consumption at 5 Years Postoperatively

BACKGROUND

Macromastia is associated with increased opioid consumption, which could potentially be the initial exposure for patients with an opioid use disorder amid an escalating opioid crisis in the United States.

OBJECTIVES

The purpose of this study was to evaluate outpatient cost of care and opioid consumption in patients with macromastia and compare those who underwent reduction mammaplasty vs those who did not have surgery.

METHODS

PearlDiver, a database encompassing a national cohort of private payers with 153 million unique patients, was queried. The study cohort included patients diagnosed with macromastia who did or did not undergo reduction mammaplasty utilizing both ICD-9 and ICD-10 and CPT codes. Outpatient cost of care and morphine milligram equivalents (MME) were calculated up to 5 years postoperatively for both cohorts.

RESULTS

At 1 to 3 years postoperatively, there was no statistically significant difference in outpatient cost of care between cohorts. At every follow-up thereafter, outpatient cost of care was higher among macromastia patients who did not undergo reduction mammaplasty, with cohort differences of US$240.68 and US$349.90 at 4 years and 5 years, respectively (P < .05). MME consumption was greater in patients who underwent reduction mammaplasty up to 30 days postoperatively (P < .01). Beyond that, there was no significant difference in MME consumption between cohorts. However, patients who did not undergo surgery had opioid consumption levels above 50 MME/day until 3 years after diagnosis of macromastia.

CONCLUSIONS

Patients with macromastia who undergo reduction mammaplasty have lower outpatient care costs than patients who do not undergo reduction mammaplasty, with safer long-term opioid consumption in alignment with current Centers for Disease Control and Prevention guidelines.

Cross-Sectional Analysis of Insurance Coverage for Lymphedema Treatments in the United States

Importance

Lymphedema is a debilitating condition that affects approximately 1 in 1000 individuals in the United States. Complete decongestive therapy is currently the standard of care, and innovative surgical techniques have demonstrated potential to further improve outcomes. Despite the growing armamentarium of treatment options, a large proportion of patients with lymphedema continue to struggle because of limited access to care.

Objective

To define the current state of insurance coverage for lymphedema treatments in the United States.

Design, Setting, and Participants

A cross-sectional analysis of insurance reimbursement for lymphedema treatments in 2022 was designed. The top 3 insurance companies per state based on market share and enrollment data maintained by the Kaiser Family Foundation were included. Established medical policies were gathered from insurance company websites and phone interviews, and descriptive statistics were performed.

Main Outcomes and Measures

Treatments of interest included nonprogrammable pneumatic compression, programmable pneumatic compression, surgical debulking, and physiologic procedures. Primary outcomes included level of coverage and criteria for coverage.

Results

This study included 67 health insurance companies representing 88.7% of the US market share. Most insurance companies offered coverage for nonprogrammable (n = 55, 82.1%) and programmable (n = 53, 79.1%) pneumatic compression. However, few insurance companies offered coverage for debulking (n = 13, 19.4%) or physiologic (n = 5, 7.5%) procedures. Geographically, the lowest rates of coverage were seen in the West, Southwest, and Southeast.

Conclusions and Relevance

This study suggests that in the United States, less than 12% of individuals with health insurance, and even fewer patients without health insurance, have access to pneumatic compression and surgical treatments for lymphedema. The stark inadequacy of insurance coverage must be addressed through research and lobbying efforts to mitigate health disparities and promote health equity among patients with lymphedema.

Quantifying Surgical Complications for Reduction Mammaplasty in Adolescents

BACKGROUND

Reduction mammaplasty is a safe, effective procedure to alleviate symptoms of adolescent macromastia. However, there remain limited data on surgical complications associated with reduction mammaplasty in adolescents, which may not be concordant with those cited for adults seeking reduction mammaplasty.

METHODS

A retrospective review was conducted of all consecutively performed reduction mammaplasty cases for symptomatic macromastia in patients aged 20 years and younger over a 7-year period from 2014 to 2021.

RESULTS

One hundred sixty total breasts were analyzed in 80 patients. Mean age was 18.3 ± 1.4 years, with an age range from 15 to 20 years. Mean body mass index was 27.17 ± 5.49 kg/m 2 . Mean reduction weight was 584.79 ± 261.19 g. A medial pedicle was used in 91%, and an inferior pedicle was used in 9%. For skin incision, a Wise pattern was used in 60%, and a short-scar was used in 40%. There was a 16.3% rate of any surgical complication, which included wound healing by secondary intention treated with local wound care. There were no significant risk factors for a surgical complication in reduction mammaplasty, and no differences in surgical complications related to skin incision type, pedicle use, or breast reduction weight. Performance of a receiver operating characteristic curve for age at surgery and complication demonstrated that there was no age cutoff where the risk of surgical complication was appreciably increased or decreased.

CONCLUSIONS

Age was not identified as a risk factor for surgical complications in adolescent reduction mammaplasty. Overall, complication rates were very low and minor in nature for adolescent reduction mammaplasty, with no significant risk factors identified.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

A Novel Pathway for Insurance Based Breast Reductions: A Method for Identifying Appropriate Surgical Candidates

Breast reductions are one of the most common plastic surgery procedures performed. The purpose of this study was to streamline the evaluation of patients requiring breast reduction by using a nurse practitioner (NP)-led class to funnel appropriate surgical candidates through the preoperative process. We performed a retrospective review of patients interested in breast reduction who enrolled in this class from March 2015 to August 2021. Of the 1310 unique patients enrolled in the initial class, 386 patients passed the initial screening and were scheduled with the NP, whereas 924 were screened out at this stage either for being an inadequate surgical candidate or not showing up for clinical visits (36.7%). An additional 185 were screened out after the consultation with NP for reasons such as lack of insurance coverage and no-show visits (20.2%). MD visits had a no-show rate of 7.08%. The decrease in no-show rates between the class-NP visit and the NP-MD visit were both significant (p < 0.001). There was no significant difference in gram estimates between providers and pathology (p = 0.5). In total, 171 patients underwent breast reduction (13.05% of the patients screened). The average time from class to surgery was 278.15 days, NP consultation to surgery was 171.48 days, and MD consultation to surgery was 59.51 days. Using a screening pathway allows for early identification of inadequate surgical candidates and therefore streamlines the screening process for optimized breast reduction candidates. Appropriate use of NP visits functions to streamline the funnel, thus decreasing the number of visits and no-show appointments for a surgeon.

"A Sign of Things to Come: Training Research Output Long-Term Scholarship in Academic Plastic Surgery."

BACKGROUNDS

Academic plastic surgery has utilized different methods to promote early involvement of trainees in research. Further analysis is needed to characterize the effects of this early emphasis and their impact on long-term academic contributions to the field.

METHODS

In October 2020, a cross-sectional study of 949 faculty from US academic plastic surgery programs was conducted using publicly available websites. Training research output for each surgeon was compared to post-training research output and other metrics measuring sustained career scholarship.

RESULTS

Increased training publications (P< 0.0001) and citations (P< 0.0001) were associated with fewer years in practice. 727 surgeons (80.0%) had ≥ 1 research article, and this group proceeded to attain significantly higher mean post-training publications per year (3.04 ± 0.14 vs. 1.45 ± 0.13, P< 0.0001) and citations per year (72.12 ± 5.04 vs. 28.39 ± 3.49, P< 0.0001) compared to the 182 (20.0%) surgeons with no training publications. For individuals, total training publications were positively correlated with post-training publications per year (P< 0.0001), a relationship also observed for citations (P< 0.0001). When controlling for years in practice, increased training publications and/or citations were significantly associated with attaining academic professor track (versus clinical professor track) position, endowed professor status, journal board position, and NIH funding (P< 0.05 for all).

CONCLUSIONS

There is a trend of increasing research productivity during plastic surgery training, and increased training output is predictive of attaining multiple measures of career academic achievement. Academic plastic surgery should continue to underscore research participation as a valuable part of the training process.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL): Are You Covered?

BACKGROUND

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a locally aggressive T-cell lymphoma that can develop following breast implantation. In 2017, and updated in 2019, the National Comprehensive Cancer Network (NCCN) recommended total capsulectomy with implant removal as definitive therapy.

OBJECTIVES

The aim of this study was to evaluate the US insurance coverage for the management of BIA-ALCL and compare it to the NCCN recommendations.

METHODS

A cross-sectional analysis of US insurance policies for coverage of BIA-ALCL treatment was conducted. Insurance companies were selected based on their market share and state enrollment. Medical necessity criteria were abstracted from the publicly available policies.

RESULTS

Of the 101 companies assessed, only 30 (30%) had a policy for the management of BIA-ALCL. Of those policies, all (n = 30, 100%) provided coverage of the implant removal of the breast diagnosed with BIA-ALCL. For the contralateral breast implant, 20 policies (67%) covered their removal, but significantly fewer did so if the implant was placed for cosmetic reasons vs medically necessary (n = 13 vs n = 20, 43% vs 67%; P = 0.0026). Twenty-one policies (70%) covered an implant reinsertion, but fewer would do so if the implant was cosmetic rather than medically necessary (n = 5, 17% vs 70%; P < 0.0001).

CONCLUSIONS

There was notable intercompany variation in the coverage of BIA-ALCL treatment, some of which is unnecessarily based on whether the original reason for the breast implant was cosmetic or medically necessary. This variability may significantly reduce access to definitive treatment in patients with a BIA-ALCL diagnosis.

Hitting the Books: A Nationwide Analysis of Advanced Degrees in Academic Plastic Surgery Faculty

OBJECTIVE

Plastic surgery is one of the most competitive and innovative fields in medicine. The role of the academic plastic surgeon continues to grow beyond clinical care, and many surgeons have pursued advanced degrees (AD) to expand their professional skillset. We present an analysis of ADs of academic plastic surgery faculty in the USA, with consideration of timing of AD attainment.

METHODS

All academic plastic surgery faculty members were identified from plastic surgery program websites, as recognized by the American Council of Academic Plastic Surgeons. ADs were defined as additional degrees beyond the primary medical degree. Outcomes included timing of AD attainment, residency rankings, institutional standings, and research productivity.

RESULTS

949 faculty members were identified, and 167 had ADs. The most common ADs were PhD (30%), MS/MSc (18%), and MBA/EMBA (17%). Timing of AD attainment was available for 146 faculty members (84.7%). Having an AD before residency was associated with matching into higher-tiered and integrated residency programs (both p < 0.05). For attending physicians, having an AD was associated with more journal editorial board positions, more publications, higher H-index, receiving NIH funding, and median number of NIH grants (adjusted for years in practice, all p<0.05). Institutional analysis revealed that employing more faculty with an AD was associated with having an integrated residency program, higher residency research ranking, and higher tier integrated residency (all p < 0.05).

CONCLUSION

ADs are growing in popularity in academic plastic surgery and are temporally associated with specific advantages in terms of residency placement, research productivity, and institutional standing.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .