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

Abstract

Background: Prominent ears affect up to 5% of the population and can lead to social and psychological concerns at a critical time of social development. It can be addressed with an otoplasty, which is often considered a cosmetic procedure. The authors assessed insurance coverage of all indications of otoplasty and their medical necessity criteria. Methods: A cross-sectional analysis was conducted of 58 insurance policies for otoplasty. The insurance companies were selected based on their state enrolment and market share. A web-based search and telephone interviews were utilized to identify the policies. Medically necessary criteria were then abstracted from the publicly available policies. Results: Of the 58 insurance policies assessed, 25 (43%) provide coverage of otoplasty. There were 2 indications for coverage: hearing loss (n = 20, 80%) and normal approximation (n = 14, 56%), which would encompass prominent ears. Normal approximation was a covered indication for significantly fewer insurers than hearing loss (56% versus 80%, P = 0.0013). Of all the otoplasty policies which covered normal approximation, 21% (n = 3) addressed protruding ears as an etiology. Prominent ears were not included in any policies which covered hearing loss. All policies inclusive of prominent ears required a protrusion of >20 mm from the temporal surface of the head (n = 3, 100%). Conclusions: There is a great discrepancy in insurance coverage of otoplasty. A greater proportion of policies cover hearing loss compared to normal approximation. The authors encourage plastic surgeons to advocate for the necessity and coverage of normal approximation by insurers.

Coverage Gaps and Inconsistencies: The Landscape of Insurance Coverage for Orthognathic Surgery in the United States

“…10 Otoplasty for prominent ear is often rejected by insurance providers, even though it significantly improves psychiatric outcomes and can be medically necessary for eyeglass or hearing aid use. 11 Care associated with cleft lip and palate is sometimes not covered by insurance providers, and 19 states lack a mandate requiring insurance providers to cover cleft lip and palate care. 22 Even head and neck cancer patients may have difficulty securing insurance coverage, which leads to significantly worse outcomes and higher mortality rates.…”

“…Many patients with private health insurance are denied medically-necessary procedures due to inconsistencies between guidelines set by medical authorities and criteria set by insurance providers. [7][8][9][10][11] When such discrepancies occur, national societies often produce evidence-based guidelines which can then be used to advocate for coverage either at the insurer-surgeon level or at the FACE 4 (3) political-legislative level. In this vein, the American Association of Oral and Maxillofacial Surgeons (AAOMS) recently produced an comprehensive evidence-based set of recommended guidelines for indications and coverage for orthognathic surgery.…”

“…Recent efforts in craniofacial surgery 11 and breast surgery 8,[14][15][16][17] have used data from the National Association of Insurance Commissioners (NAIC), the national regulatory organization for insurers in the US, to describe the landscape of insurance coverage for various surgical procedures. This has provided surgeons with valuable resources to use in advocacy efforts.…”

Insurance Coverage of Dermabrasion and Chemical Peel Procedures: A Critical Analysis of 58 American Insurance Companies

“…A potential barrier to receiving these procedures may be the cost, which could be discouraging patients from obtaining this form of treatment [20,21]. Previous literature has recognized that low rates of insurance coverage and variable criteria can hinder a patient's ability to receive certain treatments due to substantial associated out of pocket costs [22][23][24]. To further investigate cost as a limiting factor to receiving dermabrasion and chemical peel procedures, we evaluated the number of insurance companies that will cover treatment with skin resurfacing, and whether required criteria present in policies may be a barrier to receiving care.…”