United States insurance coverage of immediate lymphatic reconstruction

Abstract

IntroductionImmediate Lymphatic Reconstruction (ILR) is a prophylactic microsurgical lymphovenous bypass technique developed to prevent breast cancer related lymphedema (BCRL). We investigated current coverage policies for ILR among the top insurance providers in the United States and compared it to our institutional experience with obtaining coverage for ILR.MethodsThe study analyzed the publicly available ILR coverage statements for American insurers with the largest market share and enrollment per state to assess coverage status. Institutional ILR coverage was retrospectively analyzed using deidentified claims data and categorizing denials based on payer reason codes.ResultsOf the 63 insurance companies queried, 42.9% did not have any publicly available policies regarding ILR coverage. Of the companies with a public policy, 75.0% deny coverage for ILR. In our institutional experience, $170,071.80 was charged for ILR and $166 118.99 (97.7%) was denied by insurance.ConclusionsOver half of America's major insurance providers currently deny coverage for ILR, which is consistent with our institutional experience. Randomized trials to evaluate the efficacy of ILR are underway and focus should be shifted towards sharing high level evidence to increase insurance coverage for BCRL prevention.

Immediate lymphatic reconstruction for breast cancer-related lymphedema: current status and challenges

“…In addition, for ILR to develop into a widely used treatment throughout the world, one must not only ensure its efficacy and safety, but also solve the issue of insurance coverage for ILR. La-Anyane et al reported that more than half of the main insurance companies in the United States that have a public coverage statement deny ILR coverage ( 9 ). Furthermore, Rochlin et al indicated that the current relative value unit (RVU) allocation undervalues ILR, introducing inefficiency into breast cancer operations when combined with ILR.…”