Reduction mammaplasty: a review of managed care medical policy coverage criteria.
BACKGROUND
Insurance companies evaluate the medical necessity for breast reduction surgery based on internal company medical policies, but the correlation of insurance company criteria to the scientifically established indications for reduction mammaplasty has never been studied. The authors obtained 90 insurance company medical policies for reduction mammaplasty to determine whether the criteria on which coverage determinations are made are consistent with published data regarding the indications for this procedure.


METHODS
The authors reviewed the medical literature on reduction mammaplasty and identified what conclusions can reasonably be drawn from this literature on the common insurance criteria used to determine medical necessity for reduction mammaplasty. Conclusions based on the medical literature regarding volume of reduction, symptom presentation, conservative therapy, obesity, presence of bra strap grooving and intertrigo, and age at time of reduction were formulated, and these conclusions were compared with the criteria of 90 different health insurance reduction mammaplasty medical policies.


RESULTS
The authors 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 company medical policy requirements with respect to reduction mammaplasty are, in many cases, arbitrary and without scientific basis. Requirements for a specific volume of reduction, a minimum age, a maximum body weight, and a trial of conservative therapy are required by the majority of managed care medical policies, even though scientific support for any of these requirements is not evident in the medical literature.
Nguyen
Jesse T
JT
Lubbock, Texas; Portland, Ore.; and Scottsdale, Ariz. From Texas Tech Medical School, the Veterans Affairs Hospital Portland; the Mayo Clinic; and Oregon Health Sciences University.
Wheatley
Michael J
MJ
Schnur
Paul L
PL
Nguyen
Tuan A
TA
Winn
Shelley R
SR
D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000379:methods*; D008329:Managed Care Programs / Q000592:standards*; D014481:United States