Redefining indications for breast reduction

In this month's Plastic & Reconstructive Surgery, our profession's flagship journal, there's a study about the symptomatic relief woman receive after breast reduction who fall below the minimum threshold insurers require for coverage. To no one's surprise, even reductions less then half of the average weight removed showed dramatic symptomatic improvement at over 1 year out from surgery.

Most health insurance plans require a minimum of 500 gm (~ 1.1 lbs) of tissue to be removed per side for coverage in addition to documentation of symptoms related to their breast size. Occasionally you get some asinine form letter asking for proof of "conservative" treatment of large breasts prior to surgery, whatever the hell that is!

The authors of this study call for review by insurers of their criteria for coverage. Good luck! Insurers haven't been recording record profits by dramatically expanding their potential exposure for surgical procedures. This study doesn't really offer much that hasn't been presented to these companies for years. They're not interested in the close to three dozen papers with similar findings in the published literature.

The catch-22 here is that when coverage is expanded usually the reimbursement for the surgeon is cut. Breast reductions are long and physically hard procedures which can take 3-4 hours when you do it by yourself on large reductions. What we get paid for these is about 20-30% of what is commanded for mastopexy (breast lift) surgery, a closely related procedure which often may involve a small reduction component. It's gotten to the point for many surgeons that they just won't do it anymore as (depending upon the insurer) these hover right at the break even point for their practice when all the costs and follow-up care are figured. If you don't believe me, try finding a list of providers who will accept Medicaid assignment for these.



Post a Comment