Sunday, October 8, 2006 - 3:04 PM

Reduction Mammoplasty: A Review of Managed Care Medical Policy Criteria

Jesse Nguyen, BS, Michael Wheatley, MD, Tuan A. Nguyen, MD, DDS, and Paul L. Schnur, MD.

Concise Purpose: To evaluate whether the criteria used by health insurers to determine coverage for reduction mammoplasty are supported by the medical literature

Methods and Materials: We reviewed the medical literature on reduction mammoplasty and identified what can reasonably be concluded from this literature on the common insurance criteria used to determine medical necessity for reduction mammoplasty. Conclusions based on the medical literature regarding volume of reduction, symptom presentation, conservative therapy, obesity, presence of bra strap grooving and intertrigo, age at time of reduction were formulated, and these conclusions were compared to the criteria of 85 different health insurance reduction mammoplasty medical policies.

Summary of Results: We were unable to identify any medical policies that could be supported in entirety by the medical literature and many that are completely unfounded based on the medical literature.

Conclusions: Insurance coverage for reduction mammoplasty seems frustratingly arbitrary to most plastic surgeons. Our findings confirm that the criteria used by insurers to determine coverage for reduction mammoplasty are, for the most part, arbitrary and without relevance to the published studies on the indications for this procedure. We believe the results of this study will assist in lobbying Congress to mandate insurance coverage for reduction mammoplasty for women with symptomatic macromastia.

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