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Trends in insurance coverage for adolescent reduction mammaplasty

  • Rotem Kimia
    Affiliations
    Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, 19104, USA

    Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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  • Leanne Magee
    Affiliations
    Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
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  • Howard S. Caplan
    Affiliations
    Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
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  • David W. Low
    Affiliations
    Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
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  • Author Footnotes
    1 Dr. Oksana Jackson and Dr. Paris Butler served as co-senior authors on this study.
    Oksana A. Jackson
    Footnotes
    1 Dr. Oksana Jackson and Dr. Paris Butler served as co-senior authors on this study.
    Affiliations
    Division of Reconstructive and Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
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  • Author Footnotes
    1 Dr. Oksana Jackson and Dr. Paris Butler served as co-senior authors on this study.
    Paris D. Butler
    Correspondence
    Corresponding author. MPH 330 Cedar Street, BB330 New Haven, CT, 06519, USA.
    Footnotes
    1 Dr. Oksana Jackson and Dr. Paris Butler served as co-senior authors on this study.
    Affiliations
    Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, 06519, USA
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  • Author Footnotes
    1 Dr. Oksana Jackson and Dr. Paris Butler served as co-senior authors on this study.

      Highlights

      • Adolescent reduction mammaplasty are increasing components of pediatric plastic surgery practice.
      • Insurance preauthorization for reduction have increased over the past decade, and age cutoffs are becoming less frequent.
      • Insurance company and family income under $60K per year were independent predictors of preauthorization denial.
      • Criteria most cited for denials were lack of prior conservative management, age <18 y/o, and unmet minimum resection weight.

      Abstract

      Background

      Reduction mammaplasty is an effective intervention for symptomatic macromastia. Studies of insurance policy criteria for adult patients have demonstrated nonuniformity. This study assesses trends in insurance preauthorization for reduction mammaplasty in the adolescent population.

      Methods

      A retrospective cohort study of patients aged ≤18 years at a pediatric breast clinic between January 1, 2010 and December 31, 2020. Demographic information and clinical variables submitted to insurers were analyzed, as well as third-party payer company, provider network type, and preauthorization criteria.

      Results

      249 preauthorization requests were studied, with an approval rate of 79.5%. Submissions increased from 6 in 2010 to 59 in 2020. Variables deemed significantly associated with preauthorization denial included submission before 2015 (OR 2.04, 95% CI 1.04–3.95, p = .038), billing zip code median income <$60,000 (OR 2.11, 95% CI 1.12–3.98 p = .02), predicted resection mass below Schnur Sliding Scale threshold (OR 1.97, 95% CI 1.01–3.83 p = .047), and insurance company.

      Conclusions

      Insurance criteria for preauthorization of reduction mammaplasty in adolescents differ from adults, are not supported by clinical studies, and may exclude low-income patients from receiving care.
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