BREAST SURGERY
The Complex Insurance Reimbursement Landscape in Reduction Mammaplasty How Does the American Plastic Surgeon Navigate It? Jordan D. Frey, MD,* Peter F. Koltz, MD,Þ Derek E. Bell, MD,Þ and Howard N. Langstein, MDÞ 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. Key Words: breast, reduction, reduction mammaplasty, reduction, insurance coverage, insurance reimbursement (Ann Plast Surg 2014;72: 23Y29)
R
eduction mammaplasty (RM) is among the most commonly performed procedures by US plastic surgeons. The American Society of Plastic Surgeons (ASPS) reports that in 2011, a total of 96,277 RMs were performed. The trend in the number of RMs performed per year has remained relatively constant, with 93,083 and 78,832 procedures performed in 2010 and 2000 respectively.1 Indications for RM include signs and symptoms related to macromastia such as neck pain, back pain, intertrigo, and painful bra strap grooving. Reduction mammaplasty has been shown to be effective in alleviating both physical and psychological symptoms as well as in improving quality of life in patients with symptomatic Received June 13, 2013, and accepted for publication, after revision, September 6, 2013. From the *Institute of Reconstructive Plastic Surgery, Department of Plastic Surgery, NYU Langone Medical Center; †Division of Plastic Surgery, University of Rochester Medical Center, Rochester, NY. Conflicts of interest and sources of funding: none declared. Reprints: Howard N. Langstein, MD, Division of Plastic Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7201-0023 DOI: 10.1097/01.SAP.0000435778.81934.cd
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macromastia.2Y9 In addition, the ratio of cost to quality-adjusted lifeyears is acceptably low and comparable with other common surgical procedures.9 Insurance carriers determine the medical necessity of RM on a case-by-case basis. This differentiation, which dictates reimbursement of the procedure, is determined by a set of criteria unique to each insurance carrier. Common criteria for reimbursement of RM include a minimum weight of breast tissue removed per breast, a trial of conservative therapy, age older than 16 or 18 years, and demonstration of select symptoms. However, these criteria for reimbursement have been shown to be in disagreement with current clinical evidence.6Y8 As an illustration, 500 g per breast of resected tissue is commonly required for reimbursement despite the fact that significant clinical improvement has been shown with resected weights as low as 205 g per breast.6 Further, patient self-reporting of symptoms has been shown to define medical necessity better than current, existing criteria.10 Despite the divide between clinical evidence and insurance reimbursement criteria for RM, US plastic surgeons’ opinions of and interactions with insurance carriers and their policies have not been evaluated. In this study, US plastic surgeons were surveyed about the current environment of RM coverage and how they navigate these policies in practice. Given that there is debate among plastic surgeons as to whether they would prefer to have continued insurance coverage of the procedure given its relatively poor reimbursement, this information is extremely useful and timely.
METHODS Fourteen health insurance carriers in addition to Medicare were selected. These insurance carriers were chosen to practically represent all major regions of the United States and a full range of carrier sizes. The regions of operation; operation classification; and 2011 market share, used as a marker of insurance carrier size, were determined.11 Reduction mammaplasty policies were obtained for each carrier. Requirements for resection weight, patient age, and a trial of conservative therapy were recorded and analyzed with respect to carrier characteristics. Graphical representation and descriptive statistics were used to summarize these findings. Members of the ASPS with publicly available contact information were identified. A multiple-choice survey on the topic of RM was created. Questions were largely crafted on the basis of the senior author’s experience and were reinforced by current clinical evidence on the topic of RM and reimbursement.6Y8,12Y14 The number and the content of possible responses varied on the basis of the question being asked; an area for free-text response was included for each question. The survey was created using SurveyMonkey platform (Copyright 1999Y2012 SurveyMonkey) and was sent to each ASPS member with an e-mail address publicly listed on the ASPS Web site.15 Detailed in the survey (Appendix 1) were items assessing surgeon demographics; experience with and opinions of RM and the insurance carriers’ coverage requirements; and the surgeons’ potential courses of action given select, hypothetical patient scenarios. www.annalsplasticsurgery.com
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Demographics included the surgeon’s practice profile and approximate yearly RM case load. Questions pertaining to experience with and opinions of insurance coverage of RM included inquiries into the clinical determination of medical necessity, evaluation of patients presented for RM, resection weight requirements, compensation fees, and perception of patients’ willingness to pay out-of-pocket for RM. Hypothetical questions assessed situations in which a patient is preoperatively estimated to not meet resection requirements for coverage and an intraoperative scenario in which the measurement of tissue resected is less than that preoperatively estimated and fails to meet criteria for coverage. Data from survey responses were collected and analyzed in an anonymous fashion. Measures of central tendency as well as graphical representation and descriptive statistics were used as appropriate to analyze responses.
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FIGURE 2. Respondents’ opinionV‘‘Resection weight should be used as a criterion for coverage in RM.’’
RESULTS Insurance Carriers All insurance carriers except Medicare (14/15) require a minimum weight of resected tissue for coverage. Resection weight requirements do not vary with the carrier’s region of operation, operation classification, or 2011 market share. Twelve of fifteen carriers use the Schnur scale based on body surface area to determine weight resection requirements. An age requirement of older than 16 to 18 years is required in 9 of 15 carriers. A trial of conservative therapy is required in 11 of 15 selected carriers.
Survey A total of 3586 board-certified plastic surgeons were listed with publicly available e-mail addresses accessible via the ASPS Web site and were e-mailed surveys. Seven hundred fifty-seven surveys (21.1%) were completed and returned (14 e-mail addresses were nonfunctional). We received 14 personalized e-mail responses discussing the nuances of the subject as presented in the survey. A total of 74.1% of the responding plastic surgeons were in private practice, whereas 14.8% were in academic practice. A total of 11.1% of the respondents work in a mixed private and academic practice, and 62.1% perform approximately 11 to 50 RM procedures per year. A total of 18.4% perform fewer than 10 procedures per year, whereas 19.6% perform more than 50 procedures per year. A total of 64.1% feel that the presence of signs or symptoms related to macromastia is the most important factor in the surgeon’s determination of medical necessity; 26.8% and 10.9% believe that the weight of tissue resected and preoperative bra size, respectively, are most important in this determination. A total of 56.6% state that
FIGURE 1. Minimum resection weight required by carrier in the respondents’ regions. 24
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insurance carriers in their area require a weight of 500 g or greater per breast to be removed for coverage. A total of 31.4% state that this value is 350 to 499 g per breast, whereas 8.2% responded that this value was less than 350 g per breast. A total of 3.8% indicated that there is no such minimum value of resected tissue for coverage required by insurance carriers in their area (Fig. 1); 71.3% believe that this weight should be less than 500 g per breast. A total of 7.1% state that they feel that insurance carriers should have no required minimum weight for reimbursement of RM (Fig. 2). A total of 55.2% agree or strongly agree that the amount of tissue resected should be used as a criterion for reimbursement by insurance carriers. A total of 36.6% either disagree or strongly disagree that this should be used as a criterion, whereas 8.1% have no opinion. Meanwhile, 51.2% either strongly agree or agree that the Schnur scale should no longer be used as a method of estimating tissue to be removed; 32.8% have no opinion, whereas 16.1% either strongly disagree or disagree. A total of 42.6% agree or strongly agree that the required resection weight should be set at 205 g per breast as suggested in the literature.6 A total of 38.3% disagree or strongly disagree with this suggested minimum weight. In order of importance, the respondents indicate the use of clinical estimation (listed as most important by 89.6%), bra size (listed as second in importance by 67.6%), the Schnur scale (listed as third in importance by 51.5%), and 3-dimensional imaging (listed as fourth in importance by 87.9%) in their preoperative determination of tissue to be resected. A total of 45.2% state that they typically find a difference of 50 to 99 g per breast between their estimated value and the actual amount of tissue resected per breast. A total of 31.5% find a difference of less than 50 g per breast, and 16.0% find a difference of greater than 100 g per breast. A total of 62.2% of the respondents have not had payment for an RM denied in the past 12 months because of not meeting an insurance carrier’s coverage criteria. A total of 23.7% have had payment denied on 1 to 5 occurrences, whereas 6.3% have had this occur more than 6 times in the past 12 months. A total of 84.4% agree or strongly agree that insurance carriers should allow for a range of variation between the estimated and the actual amount of resected tissue within which a case should be reimbursed. A total of 75.9% of the respondents believe that some RM procedures should be covered procedures, whereas some believe that these should not. A total of 20.5% and 3.6% believe that RM exclusively should be and should not be an insurance-reimbursable procedure, respectively (Fig. 3). A total of 26.9% of the respondents believe that $4000 to $4999 is a reasonable surgeon’s fee to be charged if an RM procedure is preauthorized but payment subsequently comes to be denied or if RM came to be exclusively not reimbursable. A total of 22.1% and 23.8% believe that this charge should be $3000 to $3999 and $5000 to $5999, respectively (Fig. 4). * 2013 Lippincott Williams & Wilkins
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FIGURE 3. Respondents’ opinionV‘‘Should RM be a reimbursable procedure?’’
A total of 4.4% state that the surgeon’s fee should be less than $3000, and 22.8% believe that this charge should be $6000 or greater. A total of 83.9% believe that if RM was uniformly uncovered, patients could not afford and would not elect to undergo this procedure. In a scenario in which the surgeon estimates that he/she will remove 500 g per breast, which is also the minimum required weight for coverage, 61% of the surgeons would have patients sign a statement of liability for payment in the event of noncoverage for not meeting the minimum resection weight. A total of 18.9% would perform the procedure, removing only the tissue they deem necessary for symptomatic improvement, and risk having payment denied if this amount does not meet that required. In a scenario in which the surgeon has removed 400 g of tissue per breast although preoperatively obtaining preauthorization, having estimated that he/she would remove 500 to 600 g per breast, 45.6% state that they would complete the procedure without removing additional tissue and risk having payment denied. A total of 32.7% indicate that they would complete the procedure and, if payment is denied, would inform the patient that the procedure would need to be paid for out-of-pocket. A total of 11.9% would remove additional tissue until the minimum required amount for coverage was met. There were a variety of personalized e-mail responses indicating that some surgeons have ceased to perform RM because the compensation they receive from insurance carriers was too poor to validate continuation of this practice. One particular response expresses frustration that some surgeons have failed to remove enough breast tissue to meet the requirement criteria in an effort to receive out-of-pocket payment. Another response indicates that the surgeon feels that many presenting patients do not, based on symptoms, medically require RM and that altering insurance criteria for coverage may cause more patients with fewer symptoms to present for RM. One surgeon who responded personally feels that plastic surgeons have not advocated, via literature, for changes in coverage criteria, specifically in the use of the Schnur scale. Lastly, 1 surgeon states that the impending changes in overall insurance coverage in the United States may limit RM as a medically necessary procedure.
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resected for coverage, frequently based on patient characteristics. Plastic surgeons are thus tasked with determining, upon presentation, which patients will benefit from RM while concurrently navigating the differing patterns of reimbursement. The importance of further definition of clinical coverage criteria for RM is reinforced by the belief of most of the survey respondents (75.9%) that this procedure should not be universally considered either medically necessary or medically unnecessary. Most prominent insurance carriers require an adequate weight of resected tissue; signs and symptoms related to macromastia such as back pain, intertrigo, or bra strap grooving; age older than 16 to 18 years; and a trial of conservative therapy for RM to be reimbursed. However, most of the US plastic surgeons (64.1%) believe that signs and symptoms related to macromastia, rather than resection weight, is the single most important factor in the determination of the medical necessity of this procedure. Most of the surgeons listed resection weight as either the second (33.2%) or the third (40.0%) most important factor for determining medical necessity. Despite this, there were personalized responses to the survey that suggested that some objective measure such as resection weight is beneficial to ensure that patients in whom RM is truly not medically necessary do not escape paying the considerably more expensive cost associated with an out-of-pocket procedure. In this regard, 55.2% of the respondents believe that weight resection should be used as a criterion for coverage, whereas only 36.6% believe that it should not. Disagreement was found between the amount of resected tissue required for coverage by insurance carriers in the surgeons’ region and what the surgeons believed this minimum value for coverage should be. As mentioned above, US plastic surgeons believe that resected weight is not the primary factor differentiating medical necessity in RM. There is yet disagreement among surgeons regarding the determination of what weight of resected tissue should be, if at all, required by insurance carriers in their determination of reimbursement. This point is deftly evidenced by the even distribution between strong disagreement and strong agreement as to whether this amount should be the 205 g per breast suggested in the literature.6 A total of 96.2% of the respondents indicated that their region’s insurance carriers require a minimum resection weight for coverage, thus highlighting the importance of accurate preoperative estimation of tissue to be removed. Despite the development of formulas using anatomical measurements to accurately estimate this value,12Y14 our findings indicate that surgeons primarily use clinical estimation, patient bra size, and the Schnur scale in this assessment, although often finding a difference between their estimated and actual values of approximately 50 to 99 g per breast. This has led to 30% of
DISCUSSION Requirements for coverage of RM procedures vary on the basis of insurance carrier characteristics including region of operation, operative classification, and market share. In addition, insurance carriers’ policies do not agree with current clinical literature in regard to which cases are deemed medically necessary and covered and which cases are not covered.6Y8 For instance, Wagner and Alfonso7 found significant postoperative relief of symptoms independent of weight of tissue resected, which had been confirmed in previous studies.2Y7,8Y9 Most insurance carriers, however, require a certain amount of tissue to be * 2013 Lippincott Williams & Wilkins
FIGURE 4. Respondents’ opinionV‘‘What is a reasonable surgeon’s fee for RM?’’ www.annalsplasticsurgery.com
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the respondents having had at least 1 claim denied by insurance carriers after surgery was performed during the past 12 months when requirements for coverage were not met. Our study also indicates that plastic surgeons agree that a range of variation between estimated and actual values of resected weight should be allotted by insurance carriers. It is unacceptable that payment be denied after the procedure, especially when good faith efforts have been made by the surgeon, notably when cases have been precertified. Our survey results shed light onto how surgeons are negotiating the complex reimbursement landscape. In the scenario in which the surgeon estimates that the resected weight will border, will be potentially greater, or will be potentially be less than the weight required for coverage, a majority (60.7%) indicate that they would have the patient sign an ‘‘agreement of extenuating circumstance.’’ This agreement would inform the patient that the procedure will be paid for out-of-pocket if the weight does not meet the coverage criteria. Approximately 19% indicate that they would perform the procedure and, removing only the amount they deem esthetically necessary, would risk having payment denied. Further, efforts are needed to hold carriers to their precertifications because surgeons, at best, estimate the anticipated resection. Carriers might have to offer periodic ‘‘mulligans’’ to surgeons, perhaps of 50 to 75 g. Developing a universal (permissible under insurance contracts) agreement of extenuating circumstance, which may inform patients of the possibility of not meeting reimbursement requirements, is also warranted by this study. Otherwise, surgeons will not be able to offer an insurancecovered RM when there is any chance that the required resection weight will not be met. Faced with an intraoperative scenario in which adequate tissue for insurance reimbursement was not resected despite esthetics being met, most surgeons would complete the procedure and risk having payment denied. Nearly one third would complete the operation and charge the patient out-of-pocket. This may, however, not be possible if a preoperative agreement of extenuating circumstance, as discussed above, was not signed and may not be possible at all under some insurance contracts. Respondents who would resect additional tissue beyond that dictated by patient esthetics represent a minority. This scenario is possible in the breast that is preoperatively judged to be more densely glandular in nature and that is found intraoperatively to be fattier, thus leading to a lower resection weight than initially judged. As this study clarifies, RM reimbursement is variable, is confusing, is carrier dependent, and can favor the carrier over the provider in borderline cases. It is unclear whether this procedure should continue to be offered at its current insurance reimbursement rate; many personal respondents indicate that they have ceased performing RM because its time-consuming and intensive nature did not offset the fiscal benefits. The overwhelming majority of polled plastic surgeons agree that if this procedure were exclusively not covered, patients would not be able to afford and would not undergo this procedure. Even more worrisome, it is unclear how the Affordable Care Act, recently upheld by the Supreme Court, will inf luence payment of such services. Patients will most certainly desire RM in the future; hopefully, the carriers will recognize that most patients with macromastia benefit from the procedure and will cover its cost in a fair manner.
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CONCLUSIONS Insurance coverage requirements for RM are variable and incongruent with current literature as well as what plastic surgeons believe these requirements should be. Surgeons believe that signs and symptoms of macromastia are most important in this determination, whereas insurance carriers place a larger emphasis on weight of resected tissue. Although weight resections will likely continue to be necessary for coverage, plastic surgeons would prefer that a range of values be accepted. Further, an informed discussion and written agreement should be entered into, if possible, when agreeing to perform RM in the event of circumstances that would not enable the plastic surgeon to both meet the patient’s goals and satisfy insurance criteria for reimbursement. Plastic surgeons must be aware of the changing insurance landscape in regard to RM; their role in its evolution remains to be determined. REFERENCES 1. American Society of Plastic Surgeons. Report of the 2011 plastic surgery statistics. Introduction. American Society of Plastic Surgeons. 2011. Available at: http:// www.plasticsurgery.org/Documents/news-resources/statistics/2010-statisticss/ Top-Level/2010-US-cosmetic-reconstructive-plastic-surgery-minimally-invasivestatistics2.pdf. Accessed March 6, 2012. 2. Spector JA, Karp NS. Reduction mammaplasty: a significant improvement at any size. Plast Reconstr Surg. 2007;120:845Y850. 3. Singh KA, Losken A. Additional benefits of reduction mammaplasty: a systematic review of the literature. Plast Reconstr Surg. 2012;129:562Y570. 4. Rogliani M, Gentile P, Labardi L, et al. Improvement of physical and psychological symptoms after breast reduction. J Plast Reconstr Aesthet Surg. 2009;62:1647Y1649. 5. Thoma A, Sprague S, Veltri K, et al. A prospective study of patients undergoing breast reduction surgery: health-related quality of life and clinical outcomes. Plast Reconstr Surg. 2007;120:13Y26. 6. Nguyen JT, Wheatley MJ, Schnur PL, et al. Reduction mammaplasty: a review of managed care medical policy coverage criteria. Plast Reconstr Surg. 2008;121:1092Y1100. 7. Wagner DS, Alfonso DR. The influence of obesity and volume of resection on success in reduction mammaplasty: an outcomes study. Plast Reconstr Surg. 2005;115:1034Y1038. 8. Spector JA, Singh SP, Karp NS. Outcomes after breast reduction: does size really matter? Ann Plast Surg. 2008;60:505Y509. 9. Saariniemi KM, Kuokkanen HO, Ra¨sa¨nen P, et al. The cost utility of reduction mammaplasty at medium-term follow-up: a prospective study. J Plast Reconstr Aesthet Surg. 2012;65:17Y21. 10. Kerrigan CL, Collins ED, Kim HM, et al. Reduction mammaplasty: defining medical necessity. Med Decis Making. 2002;22:208Y217. 11. Novak T. Largest U.S. health insurance companies. December 7, 2011. Available at: http://www.freedombenefits.net/affordable-health-insurance-articles/Largest125-US-Health-Insurance-Companies.html. Accessed March 8, 2012. 12. Descamps MJ, Landau AG, Lazarus D, et al. A formula determining resection weights for reduction mammaplasty. Plast Reconstr Surg. 2008;121:397Y400. 13. Kocak E, Carruthers KH, McMahan JD. A reliable method for the preoperative estimation of tissue to be removed during reduction mammaplasty. Plast Reconstr Surg. 2011;127:1059Y1064. 14. Appel JZ, Wendel JJ, Zellner EG, et al. Association between preoperative measurements and resection weight in patients undergoing reduction mammaplasty. Ann Plast Surg. 2010;64:512Y515. 15. The American Society of Plastic Surgeons. The American Society of Plastic Surgeons. Available at: http://www.plasticsurgery.org/. Accessed April 24, 2012.
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APPENDIX 1: REDUCTION MAMMAPLASTY SURVEY FROM THE UNIVERSITY OF ROCHESTER MEDICAL CENTER 1. In which US state do you primarily practice? Response:____________________________________________________________ 2. In which setting do you primarily practice? A. Private practice B. Academic practice C. Private practice coupled with association to an academic practice D. Other:_______________________________________________________________ 3. On average, how many reduction mammaplasty procedures do you perform on a yearly basis? A. I do not perform reduction mammoplasties on a regular basis B. G10 C. 11Y50 D. 51Y75 E. 76Y100 F. 9100 4. Do you believe that reduction mammaplasty should be classified as a reconstructive procedure (covered by insurance providers) or a cosmetic procedure (not covered by insurance providers)? A. All reduction mammaplasty procedures should be considered reconstructive in nature and should be covered by insurance providers B. Some reduction mammaplasty procedures should be considered reconstructive in nature (and should be covered by insurance providers) and some should be considered cosmetic in nature (and should not be covered by insurance providers) C. All reduction mammaplasty procedures should be considered cosmetic in nature and should not be covered by insurance providers 5. If you believe that some reduction mammaplasties should be considered reconstructive procedures while others should be considered cosmetic procedures, what do you believe differentiates this distinction? (Please rank all responses that apply in order of importance.) A. The weight of tissue resected per breast B. The patient’s preoperative breast size C. The presence of symptoms (back pain, etc) or signs (intertrigo, etc) as a result of macromastia D. Other: _______________________________________________________________ 6. If, hypothetically, reduction mammaplasty was considered a strictly cosmetic procedure by insurance providers and was uniformly not covered, what is a reasonable surgeon’s fee that should be charged for a reduction mammaplasty? A. $1000Y$1999 B. $2000Y$2999 C. $3000Y$3999 D. $4000Y$4999 E. $5000Y$5999 F. $6000Y$6999 G. $7000Y$7999 H. $8000Y$8999 I. Q$9000 J. Other:_______________________________________________________________ 7. In your region, what is the minimum weight of tissue that must be removed per breast so that a reduction mammaplasty is a covered procedure by your region’s insurance providers? (If this value is not uniform among your area’s insurance providers, please estimate what the average value among the most prominent providers is.) A. There is no minimum weight under which the procedure would not be covered by my area’s insurance providers B. G100 g per breast C. 100Y249 g per breast D. 250Y349 g per breast E. 350Y499 g per breast F. Q500 g per breast 8. In your opinion, what should be the ‘‘cutoff’’ weight (in grams per breast) above which reduction mammaplasty is a covered procedure by insurance providers? A. There should be no minimum weight; all reduction mammoplasties should be covered procedures B. G100 g per breast C. 100Y249 g per breast * 2013 Lippincott Williams & Wilkins
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D. 250Y349 g per breast E. 350Y499 g per breast F. Q500 g per breast 9. What method(s) do you currently use to estimate, preoperatively, the weight of tissue to be removed per breast? (Please rank all responses that apply in order of importance.) A. Clinical estimation B. Bra size C. Schnur scale D. Three-dimensional (3D) imaging E. Other:_______________________________________________________________ 10. To your best estimation, what is the difference you typically find between your preoperative estimated weight and the actual weight of breast tissue per breast you remove per breast? A. Minimal if any difference B. G25 g difference per breast C. 25Y49 g difference per breast D. 50Y99 g difference per breast E. Q100 g difference per breast F. No estimation of the weight of breast tissue to be removed per breast is typically made 11. Approximately how many times in the past 12 months have you not satisfied an insurance provider’s requirements for coverage of a reduction mammaplasty and have had payment denied? A. Zero (0) occurrences B. 1Y5 occurrences C. 6Y10 occurrences D. 910 occurrences E. Not applicable (I do not bill through or participate with insurance providers) 12. You are evaluating a patient for reduction mammaplasty. You estimate that you will remove 100Y200 g of tissue per breast. Her insurance provider’s criterion for coverage requires 500 g of tissue to be removed per breast. How would you proceed? A. I would not submit this claim to an insurance provider for authorization as I would classify and perform this procedure as a mastopexy. B. I would submit this claim for authorization. If the claim is denied, I would inform the patient that this is a cosmetic procedure and that they would need to pay out-of-pocket. C. I would submit this claim for authorization and would actively lobby (eg, call the patient’s insurance provider) for this procedure to be covered by the patient’s insurance provider. D. Other: _______________________________________________________________ 13. You are evaluating a patient for reduction mammaplasty. You estimate that you will remove approximately 500 g of tissue per breast, which is the minimum required resection weight for coverage set by her insurance provider. How would you proceed? A. I would not perform a reduction mammaplasty as I am unsure that I will meet the criteria for coverage of this procedure. B. I would perform a reduction mammaplasty only if the patient agrees to pay for the procedure out-of-pocket as a cosmetic procedure. C. I would perform a reduction mammaplasty based solely on esthetic goals appropriate for this patient even if the resected weight does not meet the criteria for coverage. I recognize that, in this case, I may have payment denied and may not receive compensation. D. I would inform the patient that the resected weight may not meet the criteria for coverage and have the patient sign an agreement stating that, in this case, the patient would pay out-of-pocket for the procedure. E. I would perform a reduction mammaplasty and remove the weight of tissue needed to meet criteria for coverage even if this weight exceeds that dictated by the esthetics of the patient’s case. F. I would perform a reduction mammaplasty and, if the resected weight does not meet criteria for coverage, attempt to remove neighboring axillary or back tissue until the minimum weight required for coverage is met. G. Other: _______________________________________________________________ 14. You are in the operating room performing a reduction mammaplasty and, foreseeing a satisfactory cosmetic result, have removed 400 g of tissue per breast. Preoperatively, you estimated that you would remove 500Y600 g of tissue per breast and the claim was preauthorized by the patient’s insurance provider. How would you proceed? A. I charge each reduction mammaplasty as a cosmetic procedure, and thus, this scenario does not apply to me. B. I would resect more breast tissue until the total weight of tissue resected meets criteria for coverage even though this exceeds the esthetics dictated in the patient’s case. C. I would complete the operation, accepting that payment may be denied by her insurance provider and I may not receive compensation. D. I would complete the operation, and if payment is denied, I would bill the patient out-of-pocket for the procedure. E. I would resect additional adjacent breast tissue until the minimum required weight for coverage is met. 28
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F. I would use an alternate method of increasing the weight of the resected tissue until the minimum required weight for coverage is met. G. Other: _______________________________________________________________ 15. Insurance providers should allow for a range of variation (eg, T50 g) between estimated and actual weight of tissue to be removed within which the procedure will be covered. Strongly Disagree Disagree No Opinion Agree Strongly Agree 16. The Schnur scale should no longer be used by insurance providers to gauge whether the weight of tissue resected is deemed appropriate for coverage. Strongly Disagree Disagree No Opinion Agree Strongly Agree 17. Insurance providers should not use the weight of tissue resected at all as a criterion for coverage. Strongly Disagree Disagree No Opinion Agree Strongly Agree 18. The minimum required weight of tissue resected per breast for coverage of reduction mammaplasty should be uniformly set at 205 g per breast as suggested in the literature.6 Strongly Disagree Disagree No Opinion Agree Strongly Agree 19. If reduction mammaplasty came to be uniformly not covered by insurance providers, the majority of patients desiring breast reduction could afford and would still elect to undergo reduction mammaplasty. Strongly Disagree Disagree No Opinion Agree Strongly Agree
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The Complex Insurance Reimbursement Landscape in Reduction Mammaplasty How Does the American Plastic Surgeon Navigate It? Jordan D. Frey, MD,* Peter F. Koltz, MD,Þ Derek E. Bell, MD,Þ and Howard N. Langstein, MDÞ 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. Key Words: breast, reduction, reduction mammaplasty, reduction, insurance coverage, insurance reimbursement (Ann Plast Surg 2014;72: 23Y29)
R
eduction mammaplasty (RM) is among the most commonly performed procedures by US plastic surgeons. The American Society of Plastic Surgeons (ASPS) reports that in 2011, a total of 96,277 RMs were performed. The trend in the number of RMs performed per year has remained relatively constant, with 93,083 and 78,832 procedures performed in 2010 and 2000 respectively.1 Indications for RM include signs and symptoms related to macromastia such as neck pain, back pain, intertrigo, and painful bra strap grooving. Reduction mammaplasty has been shown to be effective in alleviating both physical and psychological symptoms as well as in improving quality of life in patients with symptomatic Received June 13, 2013, and accepted for publication, after revision, September 6, 2013. From the *Institute of Reconstructive Plastic Surgery, Department of Plastic Surgery, NYU Langone Medical Center; †Division of Plastic Surgery, University of Rochester Medical Center, Rochester, NY. Conflicts of interest and sources of funding: none declared. Reprints: Howard N. Langstein, MD, Division of Plastic Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7201-0023 DOI: 10.1097/01.SAP.0000435778.81934.cd
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macromastia.2Y9 In addition, the ratio of cost to quality-adjusted lifeyears is acceptably low and comparable with other common surgical procedures.9 Insurance carriers determine the medical necessity of RM on a case-by-case basis. This differentiation, which dictates reimbursement of the procedure, is determined by a set of criteria unique to each insurance carrier. Common criteria for reimbursement of RM include a minimum weight of breast tissue removed per breast, a trial of conservative therapy, age older than 16 or 18 years, and demonstration of select symptoms. However, these criteria for reimbursement have been shown to be in disagreement with current clinical evidence.6Y8 As an illustration, 500 g per breast of resected tissue is commonly required for reimbursement despite the fact that significant clinical improvement has been shown with resected weights as low as 205 g per breast.6 Further, patient self-reporting of symptoms has been shown to define medical necessity better than current, existing criteria.10 Despite the divide between clinical evidence and insurance reimbursement criteria for RM, US plastic surgeons’ opinions of and interactions with insurance carriers and their policies have not been evaluated. In this study, US plastic surgeons were surveyed about the current environment of RM coverage and how they navigate these policies in practice. Given that there is debate among plastic surgeons as to whether they would prefer to have continued insurance coverage of the procedure given its relatively poor reimbursement, this information is extremely useful and timely.
METHODS Fourteen health insurance carriers in addition to Medicare were selected. These insurance carriers were chosen to practically represent all major regions of the United States and a full range of carrier sizes. The regions of operation; operation classification; and 2011 market share, used as a marker of insurance carrier size, were determined.11 Reduction mammaplasty policies were obtained for each carrier. Requirements for resection weight, patient age, and a trial of conservative therapy were recorded and analyzed with respect to carrier characteristics. Graphical representation and descriptive statistics were used to summarize these findings. Members of the ASPS with publicly available contact information were identified. A multiple-choice survey on the topic of RM was created. Questions were largely crafted on the basis of the senior author’s experience and were reinforced by current clinical evidence on the topic of RM and reimbursement.6Y8,12Y14 The number and the content of possible responses varied on the basis of the question being asked; an area for free-text response was included for each question. The survey was created using SurveyMonkey platform (Copyright 1999Y2012 SurveyMonkey) and was sent to each ASPS member with an e-mail address publicly listed on the ASPS Web site.15 Detailed in the survey (Appendix 1) were items assessing surgeon demographics; experience with and opinions of RM and the insurance carriers’ coverage requirements; and the surgeons’ potential courses of action given select, hypothetical patient scenarios. www.annalsplasticsurgery.com
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Demographics included the surgeon’s practice profile and approximate yearly RM case load. Questions pertaining to experience with and opinions of insurance coverage of RM included inquiries into the clinical determination of medical necessity, evaluation of patients presented for RM, resection weight requirements, compensation fees, and perception of patients’ willingness to pay out-of-pocket for RM. Hypothetical questions assessed situations in which a patient is preoperatively estimated to not meet resection requirements for coverage and an intraoperative scenario in which the measurement of tissue resected is less than that preoperatively estimated and fails to meet criteria for coverage. Data from survey responses were collected and analyzed in an anonymous fashion. Measures of central tendency as well as graphical representation and descriptive statistics were used as appropriate to analyze responses.
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FIGURE 2. Respondents’ opinionV‘‘Resection weight should be used as a criterion for coverage in RM.’’
RESULTS Insurance Carriers All insurance carriers except Medicare (14/15) require a minimum weight of resected tissue for coverage. Resection weight requirements do not vary with the carrier’s region of operation, operation classification, or 2011 market share. Twelve of fifteen carriers use the Schnur scale based on body surface area to determine weight resection requirements. An age requirement of older than 16 to 18 years is required in 9 of 15 carriers. A trial of conservative therapy is required in 11 of 15 selected carriers.
Survey A total of 3586 board-certified plastic surgeons were listed with publicly available e-mail addresses accessible via the ASPS Web site and were e-mailed surveys. Seven hundred fifty-seven surveys (21.1%) were completed and returned (14 e-mail addresses were nonfunctional). We received 14 personalized e-mail responses discussing the nuances of the subject as presented in the survey. A total of 74.1% of the responding plastic surgeons were in private practice, whereas 14.8% were in academic practice. A total of 11.1% of the respondents work in a mixed private and academic practice, and 62.1% perform approximately 11 to 50 RM procedures per year. A total of 18.4% perform fewer than 10 procedures per year, whereas 19.6% perform more than 50 procedures per year. A total of 64.1% feel that the presence of signs or symptoms related to macromastia is the most important factor in the surgeon’s determination of medical necessity; 26.8% and 10.9% believe that the weight of tissue resected and preoperative bra size, respectively, are most important in this determination. A total of 56.6% state that
FIGURE 1. Minimum resection weight required by carrier in the respondents’ regions. 24
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insurance carriers in their area require a weight of 500 g or greater per breast to be removed for coverage. A total of 31.4% state that this value is 350 to 499 g per breast, whereas 8.2% responded that this value was less than 350 g per breast. A total of 3.8% indicated that there is no such minimum value of resected tissue for coverage required by insurance carriers in their area (Fig. 1); 71.3% believe that this weight should be less than 500 g per breast. A total of 7.1% state that they feel that insurance carriers should have no required minimum weight for reimbursement of RM (Fig. 2). A total of 55.2% agree or strongly agree that the amount of tissue resected should be used as a criterion for reimbursement by insurance carriers. A total of 36.6% either disagree or strongly disagree that this should be used as a criterion, whereas 8.1% have no opinion. Meanwhile, 51.2% either strongly agree or agree that the Schnur scale should no longer be used as a method of estimating tissue to be removed; 32.8% have no opinion, whereas 16.1% either strongly disagree or disagree. A total of 42.6% agree or strongly agree that the required resection weight should be set at 205 g per breast as suggested in the literature.6 A total of 38.3% disagree or strongly disagree with this suggested minimum weight. In order of importance, the respondents indicate the use of clinical estimation (listed as most important by 89.6%), bra size (listed as second in importance by 67.6%), the Schnur scale (listed as third in importance by 51.5%), and 3-dimensional imaging (listed as fourth in importance by 87.9%) in their preoperative determination of tissue to be resected. A total of 45.2% state that they typically find a difference of 50 to 99 g per breast between their estimated value and the actual amount of tissue resected per breast. A total of 31.5% find a difference of less than 50 g per breast, and 16.0% find a difference of greater than 100 g per breast. A total of 62.2% of the respondents have not had payment for an RM denied in the past 12 months because of not meeting an insurance carrier’s coverage criteria. A total of 23.7% have had payment denied on 1 to 5 occurrences, whereas 6.3% have had this occur more than 6 times in the past 12 months. A total of 84.4% agree or strongly agree that insurance carriers should allow for a range of variation between the estimated and the actual amount of resected tissue within which a case should be reimbursed. A total of 75.9% of the respondents believe that some RM procedures should be covered procedures, whereas some believe that these should not. A total of 20.5% and 3.6% believe that RM exclusively should be and should not be an insurance-reimbursable procedure, respectively (Fig. 3). A total of 26.9% of the respondents believe that $4000 to $4999 is a reasonable surgeon’s fee to be charged if an RM procedure is preauthorized but payment subsequently comes to be denied or if RM came to be exclusively not reimbursable. A total of 22.1% and 23.8% believe that this charge should be $3000 to $3999 and $5000 to $5999, respectively (Fig. 4). * 2013 Lippincott Williams & Wilkins
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FIGURE 3. Respondents’ opinionV‘‘Should RM be a reimbursable procedure?’’
A total of 4.4% state that the surgeon’s fee should be less than $3000, and 22.8% believe that this charge should be $6000 or greater. A total of 83.9% believe that if RM was uniformly uncovered, patients could not afford and would not elect to undergo this procedure. In a scenario in which the surgeon estimates that he/she will remove 500 g per breast, which is also the minimum required weight for coverage, 61% of the surgeons would have patients sign a statement of liability for payment in the event of noncoverage for not meeting the minimum resection weight. A total of 18.9% would perform the procedure, removing only the tissue they deem necessary for symptomatic improvement, and risk having payment denied if this amount does not meet that required. In a scenario in which the surgeon has removed 400 g of tissue per breast although preoperatively obtaining preauthorization, having estimated that he/she would remove 500 to 600 g per breast, 45.6% state that they would complete the procedure without removing additional tissue and risk having payment denied. A total of 32.7% indicate that they would complete the procedure and, if payment is denied, would inform the patient that the procedure would need to be paid for out-of-pocket. A total of 11.9% would remove additional tissue until the minimum required amount for coverage was met. There were a variety of personalized e-mail responses indicating that some surgeons have ceased to perform RM because the compensation they receive from insurance carriers was too poor to validate continuation of this practice. One particular response expresses frustration that some surgeons have failed to remove enough breast tissue to meet the requirement criteria in an effort to receive out-of-pocket payment. Another response indicates that the surgeon feels that many presenting patients do not, based on symptoms, medically require RM and that altering insurance criteria for coverage may cause more patients with fewer symptoms to present for RM. One surgeon who responded personally feels that plastic surgeons have not advocated, via literature, for changes in coverage criteria, specifically in the use of the Schnur scale. Lastly, 1 surgeon states that the impending changes in overall insurance coverage in the United States may limit RM as a medically necessary procedure.
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resected for coverage, frequently based on patient characteristics. Plastic surgeons are thus tasked with determining, upon presentation, which patients will benefit from RM while concurrently navigating the differing patterns of reimbursement. The importance of further definition of clinical coverage criteria for RM is reinforced by the belief of most of the survey respondents (75.9%) that this procedure should not be universally considered either medically necessary or medically unnecessary. Most prominent insurance carriers require an adequate weight of resected tissue; signs and symptoms related to macromastia such as back pain, intertrigo, or bra strap grooving; age older than 16 to 18 years; and a trial of conservative therapy for RM to be reimbursed. However, most of the US plastic surgeons (64.1%) believe that signs and symptoms related to macromastia, rather than resection weight, is the single most important factor in the determination of the medical necessity of this procedure. Most of the surgeons listed resection weight as either the second (33.2%) or the third (40.0%) most important factor for determining medical necessity. Despite this, there were personalized responses to the survey that suggested that some objective measure such as resection weight is beneficial to ensure that patients in whom RM is truly not medically necessary do not escape paying the considerably more expensive cost associated with an out-of-pocket procedure. In this regard, 55.2% of the respondents believe that weight resection should be used as a criterion for coverage, whereas only 36.6% believe that it should not. Disagreement was found between the amount of resected tissue required for coverage by insurance carriers in the surgeons’ region and what the surgeons believed this minimum value for coverage should be. As mentioned above, US plastic surgeons believe that resected weight is not the primary factor differentiating medical necessity in RM. There is yet disagreement among surgeons regarding the determination of what weight of resected tissue should be, if at all, required by insurance carriers in their determination of reimbursement. This point is deftly evidenced by the even distribution between strong disagreement and strong agreement as to whether this amount should be the 205 g per breast suggested in the literature.6 A total of 96.2% of the respondents indicated that their region’s insurance carriers require a minimum resection weight for coverage, thus highlighting the importance of accurate preoperative estimation of tissue to be removed. Despite the development of formulas using anatomical measurements to accurately estimate this value,12Y14 our findings indicate that surgeons primarily use clinical estimation, patient bra size, and the Schnur scale in this assessment, although often finding a difference between their estimated and actual values of approximately 50 to 99 g per breast. This has led to 30% of
DISCUSSION Requirements for coverage of RM procedures vary on the basis of insurance carrier characteristics including region of operation, operative classification, and market share. In addition, insurance carriers’ policies do not agree with current clinical literature in regard to which cases are deemed medically necessary and covered and which cases are not covered.6Y8 For instance, Wagner and Alfonso7 found significant postoperative relief of symptoms independent of weight of tissue resected, which had been confirmed in previous studies.2Y7,8Y9 Most insurance carriers, however, require a certain amount of tissue to be * 2013 Lippincott Williams & Wilkins
FIGURE 4. Respondents’ opinionV‘‘What is a reasonable surgeon’s fee for RM?’’ www.annalsplasticsurgery.com
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the respondents having had at least 1 claim denied by insurance carriers after surgery was performed during the past 12 months when requirements for coverage were not met. Our study also indicates that plastic surgeons agree that a range of variation between estimated and actual values of resected weight should be allotted by insurance carriers. It is unacceptable that payment be denied after the procedure, especially when good faith efforts have been made by the surgeon, notably when cases have been precertified. Our survey results shed light onto how surgeons are negotiating the complex reimbursement landscape. In the scenario in which the surgeon estimates that the resected weight will border, will be potentially greater, or will be potentially be less than the weight required for coverage, a majority (60.7%) indicate that they would have the patient sign an ‘‘agreement of extenuating circumstance.’’ This agreement would inform the patient that the procedure will be paid for out-of-pocket if the weight does not meet the coverage criteria. Approximately 19% indicate that they would perform the procedure and, removing only the amount they deem esthetically necessary, would risk having payment denied. Further, efforts are needed to hold carriers to their precertifications because surgeons, at best, estimate the anticipated resection. Carriers might have to offer periodic ‘‘mulligans’’ to surgeons, perhaps of 50 to 75 g. Developing a universal (permissible under insurance contracts) agreement of extenuating circumstance, which may inform patients of the possibility of not meeting reimbursement requirements, is also warranted by this study. Otherwise, surgeons will not be able to offer an insurancecovered RM when there is any chance that the required resection weight will not be met. Faced with an intraoperative scenario in which adequate tissue for insurance reimbursement was not resected despite esthetics being met, most surgeons would complete the procedure and risk having payment denied. Nearly one third would complete the operation and charge the patient out-of-pocket. This may, however, not be possible if a preoperative agreement of extenuating circumstance, as discussed above, was not signed and may not be possible at all under some insurance contracts. Respondents who would resect additional tissue beyond that dictated by patient esthetics represent a minority. This scenario is possible in the breast that is preoperatively judged to be more densely glandular in nature and that is found intraoperatively to be fattier, thus leading to a lower resection weight than initially judged. As this study clarifies, RM reimbursement is variable, is confusing, is carrier dependent, and can favor the carrier over the provider in borderline cases. It is unclear whether this procedure should continue to be offered at its current insurance reimbursement rate; many personal respondents indicate that they have ceased performing RM because its time-consuming and intensive nature did not offset the fiscal benefits. The overwhelming majority of polled plastic surgeons agree that if this procedure were exclusively not covered, patients would not be able to afford and would not undergo this procedure. Even more worrisome, it is unclear how the Affordable Care Act, recently upheld by the Supreme Court, will inf luence payment of such services. Patients will most certainly desire RM in the future; hopefully, the carriers will recognize that most patients with macromastia benefit from the procedure and will cover its cost in a fair manner.
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CONCLUSIONS Insurance coverage requirements for RM are variable and incongruent with current literature as well as what plastic surgeons believe these requirements should be. Surgeons believe that signs and symptoms of macromastia are most important in this determination, whereas insurance carriers place a larger emphasis on weight of resected tissue. Although weight resections will likely continue to be necessary for coverage, plastic surgeons would prefer that a range of values be accepted. Further, an informed discussion and written agreement should be entered into, if possible, when agreeing to perform RM in the event of circumstances that would not enable the plastic surgeon to both meet the patient’s goals and satisfy insurance criteria for reimbursement. Plastic surgeons must be aware of the changing insurance landscape in regard to RM; their role in its evolution remains to be determined. REFERENCES 1. American Society of Plastic Surgeons. Report of the 2011 plastic surgery statistics. Introduction. American Society of Plastic Surgeons. 2011. Available at: http:// www.plasticsurgery.org/Documents/news-resources/statistics/2010-statisticss/ Top-Level/2010-US-cosmetic-reconstructive-plastic-surgery-minimally-invasivestatistics2.pdf. Accessed March 6, 2012. 2. Spector JA, Karp NS. Reduction mammaplasty: a significant improvement at any size. Plast Reconstr Surg. 2007;120:845Y850. 3. Singh KA, Losken A. Additional benefits of reduction mammaplasty: a systematic review of the literature. Plast Reconstr Surg. 2012;129:562Y570. 4. Rogliani M, Gentile P, Labardi L, et al. Improvement of physical and psychological symptoms after breast reduction. J Plast Reconstr Aesthet Surg. 2009;62:1647Y1649. 5. Thoma A, Sprague S, Veltri K, et al. A prospective study of patients undergoing breast reduction surgery: health-related quality of life and clinical outcomes. Plast Reconstr Surg. 2007;120:13Y26. 6. Nguyen JT, Wheatley MJ, Schnur PL, et al. Reduction mammaplasty: a review of managed care medical policy coverage criteria. Plast Reconstr Surg. 2008;121:1092Y1100. 7. Wagner DS, Alfonso DR. The influence of obesity and volume of resection on success in reduction mammaplasty: an outcomes study. Plast Reconstr Surg. 2005;115:1034Y1038. 8. Spector JA, Singh SP, Karp NS. Outcomes after breast reduction: does size really matter? Ann Plast Surg. 2008;60:505Y509. 9. Saariniemi KM, Kuokkanen HO, Ra¨sa¨nen P, et al. The cost utility of reduction mammaplasty at medium-term follow-up: a prospective study. J Plast Reconstr Aesthet Surg. 2012;65:17Y21. 10. Kerrigan CL, Collins ED, Kim HM, et al. Reduction mammaplasty: defining medical necessity. Med Decis Making. 2002;22:208Y217. 11. Novak T. Largest U.S. health insurance companies. December 7, 2011. Available at: http://www.freedombenefits.net/affordable-health-insurance-articles/Largest125-US-Health-Insurance-Companies.html. Accessed March 8, 2012. 12. Descamps MJ, Landau AG, Lazarus D, et al. A formula determining resection weights for reduction mammaplasty. Plast Reconstr Surg. 2008;121:397Y400. 13. Kocak E, Carruthers KH, McMahan JD. A reliable method for the preoperative estimation of tissue to be removed during reduction mammaplasty. Plast Reconstr Surg. 2011;127:1059Y1064. 14. Appel JZ, Wendel JJ, Zellner EG, et al. Association between preoperative measurements and resection weight in patients undergoing reduction mammaplasty. Ann Plast Surg. 2010;64:512Y515. 15. The American Society of Plastic Surgeons. The American Society of Plastic Surgeons. Available at: http://www.plasticsurgery.org/. Accessed April 24, 2012.
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APPENDIX 1: REDUCTION MAMMAPLASTY SURVEY FROM THE UNIVERSITY OF ROCHESTER MEDICAL CENTER 1. In which US state do you primarily practice? Response:____________________________________________________________ 2. In which setting do you primarily practice? A. Private practice B. Academic practice C. Private practice coupled with association to an academic practice D. Other:_______________________________________________________________ 3. On average, how many reduction mammaplasty procedures do you perform on a yearly basis? A. I do not perform reduction mammoplasties on a regular basis B. G10 C. 11Y50 D. 51Y75 E. 76Y100 F. 9100 4. Do you believe that reduction mammaplasty should be classified as a reconstructive procedure (covered by insurance providers) or a cosmetic procedure (not covered by insurance providers)? A. All reduction mammaplasty procedures should be considered reconstructive in nature and should be covered by insurance providers B. Some reduction mammaplasty procedures should be considered reconstructive in nature (and should be covered by insurance providers) and some should be considered cosmetic in nature (and should not be covered by insurance providers) C. All reduction mammaplasty procedures should be considered cosmetic in nature and should not be covered by insurance providers 5. If you believe that some reduction mammaplasties should be considered reconstructive procedures while others should be considered cosmetic procedures, what do you believe differentiates this distinction? (Please rank all responses that apply in order of importance.) A. The weight of tissue resected per breast B. The patient’s preoperative breast size C. The presence of symptoms (back pain, etc) or signs (intertrigo, etc) as a result of macromastia D. Other: _______________________________________________________________ 6. If, hypothetically, reduction mammaplasty was considered a strictly cosmetic procedure by insurance providers and was uniformly not covered, what is a reasonable surgeon’s fee that should be charged for a reduction mammaplasty? A. $1000Y$1999 B. $2000Y$2999 C. $3000Y$3999 D. $4000Y$4999 E. $5000Y$5999 F. $6000Y$6999 G. $7000Y$7999 H. $8000Y$8999 I. Q$9000 J. Other:_______________________________________________________________ 7. In your region, what is the minimum weight of tissue that must be removed per breast so that a reduction mammaplasty is a covered procedure by your region’s insurance providers? (If this value is not uniform among your area’s insurance providers, please estimate what the average value among the most prominent providers is.) A. There is no minimum weight under which the procedure would not be covered by my area’s insurance providers B. G100 g per breast C. 100Y249 g per breast D. 250Y349 g per breast E. 350Y499 g per breast F. Q500 g per breast 8. In your opinion, what should be the ‘‘cutoff’’ weight (in grams per breast) above which reduction mammaplasty is a covered procedure by insurance providers? A. There should be no minimum weight; all reduction mammoplasties should be covered procedures B. G100 g per breast C. 100Y249 g per breast * 2013 Lippincott Williams & Wilkins
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D. 250Y349 g per breast E. 350Y499 g per breast F. Q500 g per breast 9. What method(s) do you currently use to estimate, preoperatively, the weight of tissue to be removed per breast? (Please rank all responses that apply in order of importance.) A. Clinical estimation B. Bra size C. Schnur scale D. Three-dimensional (3D) imaging E. Other:_______________________________________________________________ 10. To your best estimation, what is the difference you typically find between your preoperative estimated weight and the actual weight of breast tissue per breast you remove per breast? A. Minimal if any difference B. G25 g difference per breast C. 25Y49 g difference per breast D. 50Y99 g difference per breast E. Q100 g difference per breast F. No estimation of the weight of breast tissue to be removed per breast is typically made 11. Approximately how many times in the past 12 months have you not satisfied an insurance provider’s requirements for coverage of a reduction mammaplasty and have had payment denied? A. Zero (0) occurrences B. 1Y5 occurrences C. 6Y10 occurrences D. 910 occurrences E. Not applicable (I do not bill through or participate with insurance providers) 12. You are evaluating a patient for reduction mammaplasty. You estimate that you will remove 100Y200 g of tissue per breast. Her insurance provider’s criterion for coverage requires 500 g of tissue to be removed per breast. How would you proceed? A. I would not submit this claim to an insurance provider for authorization as I would classify and perform this procedure as a mastopexy. B. I would submit this claim for authorization. If the claim is denied, I would inform the patient that this is a cosmetic procedure and that they would need to pay out-of-pocket. C. I would submit this claim for authorization and would actively lobby (eg, call the patient’s insurance provider) for this procedure to be covered by the patient’s insurance provider. D. Other: _______________________________________________________________ 13. You are evaluating a patient for reduction mammaplasty. You estimate that you will remove approximately 500 g of tissue per breast, which is the minimum required resection weight for coverage set by her insurance provider. How would you proceed? A. I would not perform a reduction mammaplasty as I am unsure that I will meet the criteria for coverage of this procedure. B. I would perform a reduction mammaplasty only if the patient agrees to pay for the procedure out-of-pocket as a cosmetic procedure. C. I would perform a reduction mammaplasty based solely on esthetic goals appropriate for this patient even if the resected weight does not meet the criteria for coverage. I recognize that, in this case, I may have payment denied and may not receive compensation. D. I would inform the patient that the resected weight may not meet the criteria for coverage and have the patient sign an agreement stating that, in this case, the patient would pay out-of-pocket for the procedure. E. I would perform a reduction mammaplasty and remove the weight of tissue needed to meet criteria for coverage even if this weight exceeds that dictated by the esthetics of the patient’s case. F. I would perform a reduction mammaplasty and, if the resected weight does not meet criteria for coverage, attempt to remove neighboring axillary or back tissue until the minimum weight required for coverage is met. G. Other: _______________________________________________________________ 14. You are in the operating room performing a reduction mammaplasty and, foreseeing a satisfactory cosmetic result, have removed 400 g of tissue per breast. Preoperatively, you estimated that you would remove 500Y600 g of tissue per breast and the claim was preauthorized by the patient’s insurance provider. How would you proceed? A. I charge each reduction mammaplasty as a cosmetic procedure, and thus, this scenario does not apply to me. B. I would resect more breast tissue until the total weight of tissue resected meets criteria for coverage even though this exceeds the esthetics dictated in the patient’s case. C. I would complete the operation, accepting that payment may be denied by her insurance provider and I may not receive compensation. D. I would complete the operation, and if payment is denied, I would bill the patient out-of-pocket for the procedure. E. I would resect additional adjacent breast tissue until the minimum required weight for coverage is met. 28
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F. I would use an alternate method of increasing the weight of the resected tissue until the minimum required weight for coverage is met. G. Other: _______________________________________________________________ 15. Insurance providers should allow for a range of variation (eg, T50 g) between estimated and actual weight of tissue to be removed within which the procedure will be covered. Strongly Disagree Disagree No Opinion Agree Strongly Agree 16. The Schnur scale should no longer be used by insurance providers to gauge whether the weight of tissue resected is deemed appropriate for coverage. Strongly Disagree Disagree No Opinion Agree Strongly Agree 17. Insurance providers should not use the weight of tissue resected at all as a criterion for coverage. Strongly Disagree Disagree No Opinion Agree Strongly Agree 18. The minimum required weight of tissue resected per breast for coverage of reduction mammaplasty should be uniformly set at 205 g per breast as suggested in the literature.6 Strongly Disagree Disagree No Opinion Agree Strongly Agree 19. If reduction mammaplasty came to be uniformly not covered by insurance providers, the majority of patients desiring breast reduction could afford and would still elect to undergo reduction mammaplasty. Strongly Disagree Disagree No Opinion Agree Strongly Agree
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