Rising Rates of Insurance Denial for Breast Reduction Surgery

Breast reduction surgery (reduction mammaplasty) is the standard of care for women with physical and psychological symptoms caused by overlarge breasts (macromastia). In fact, according to the American Society of Plastic Surgeons, more than 46,000 breast reduction procedures were performed in 2019, a six percent increase compared to 2018; but in recent years, insurance companies have become more likely to deny coverage for this medically recommended procedure.

"The rate of pre-authorization denials for reduction mammaplasty is high and has been steadily increasing," comments senior author Linda G. Phillips, MD, of University of Texas Medical Branch, Galveston. "Plastic surgeons are now required to have deep knowledge of insurance policies for delivery of high-quality care."

The researchers analyzed their hospital's experience with insurance preauthorization for reduction mammaplasty in 295 patients from 2012 to 2017. Trends in approval or denial of insurance coverage were analyzed, including reasons for denial and differences between insurance companies. The study appears in the August issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

Overall, 28 percent of patients were denied coverage for breast-reduction surgery. "Our study showed that the rates of insurance denials have been steadily increasing, from 18 percent in 2012 to 41 percent in 2017," Dr. Phillips and coauthors write. The decision was appealed in 18 out of 83 denials; 13 of the appeals were successful.

About 82 percent of patients had private insurance and 18 percent were covered by Medicaid. (The study excluded patients covered by Medicare.) The average denial rate was 32 percent for patients with private insurance, compared to approximately nine percent for Medicaid patients. Denial rates varied widely between different insurance carriers: from a low of about 12 percent to a high of 62 percent.

The study also looked at the reasons for insurance denials. Thirty percent of preauthorizations were denied because the insurance policy specifically excluded reduction mammaplasty or the surgeon was out of network. Another 39 percent were rejected because the patient did not meet the insurer's medical criteria or due to inadequate documentation.

Twelve percent of cases were denied because the weight of the predicted or actual breast tissue to be removed was "less than the minimum acceptable resection rate." (In the remaining 19 percent of cases, the reason for denial wasn't adequately documented.)

Dr. Phillips and colleagues raise special concerns about denials due to inadequate documentation or not meeting medical criteria. "It has been suggested that insurance coverage criteria are used arbitrarily, without scientific evidence and not consistent with clinical practice, said Dr. Phillips. "Some insurance companies won't cover breast reduction unless the surgeon plans to remove at least 500 grams (more than one pound) of breast tissue on both sides, even though studies have shown that the amount of tissue removed is unrelated to relief of symptoms."

Reduction mammaplasty is regarded as a medically necessary procedure for women with macromastia. Numerous studies have demonstrated its benefits in reducing symptoms (such as back and neck pain) and improving psychological well-being (such as poor body image and low self-esteem) in women with overlarge breasts.

"This study highlights the importance of proper documentation, as it may improve the rates of insurance approval for patients with symptomatic macromastia," the researchers write. Their experience suggests that appeal processes may increase the chances of approval and reimbursement.

"The health insurance industry may want to consider utilizing current literature and available scientific guidelines published by ASPS," Dr. Phillips and coauthors add. They suggest that financial analyses might show an economic benefit of reduction mammaplasty, compared to the need for other long-term treatments to manage symptoms related to macromastia.

Plastic and Reconstructive Surgery® is published by Wolters Kluwer.

Click here to read "Insurance Denials in Reduction Mammaplasty: How Can We Serve Our Patients Better?"

Article: "Insurance Denials in Reduction Mammaplasty: How Can We Serve Our Patients Better?" (doi: 10.1097/PRS.0000000000006968)