Insurance Coverage of Reduction Mammaplasty: A Need for New Criteria

Abstract

Plastic and Reconstructive Surgery • September 2021 surgical literature, and professional determinations of estimated resection weights by practicing physicians, there is a lack of consensus within the plastic surgery community on how to best determine estimated resection weight and the use of this coverage requirement.Given that body surface area-based estimated resection weight formulas are often inconsistent and not necessarily reflective of the patient burden of macromastia, realignment of reduction mammaplasty-related insurance coverage toward quality-of-life measures may be one path forward. Patient-reported quality-of-life measures are evidence-based (e.g., the BREAST-Q, a psychometrically validated quality-of-life questionnaire). 5 These questionnaires are frequently used by health professionals as a method of evaluating individual patient experience, with domains related to satisfaction with the breasts, and others that target specific functional symptoms of patients with macromastia. A prime example is the severity of ptosis, which body surface area-based formulas fail to capture but undoubtedly impacts macromastia symptomatology. Regardless of the exact breast mass or body surface area, each patient may experience pain, headaches, skin irritation, and other symptoms differently. Therefore, quality-of-life questionnaires are more reflective of everyday practice (as opposed to body surface area-based formulas), and patients with diminished quality of life as a result of breast hypertrophy should be considered for coverage. As the plastic surgery community considers ways to optimize clinical outcomes and provide equitable care, reconsidering how our patients receive care-such as the metrics used to determine insurance coverage for reduction mammaplasty-is needed.