From the Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine; and the Department of Plastic Surgery, Johns Hopkins Hospital/University of Maryland School of Medicine.
Plast Reconstr Surg. 2020 Feb;145(2):545-554. doi: 10.1097/PRS.0000000000006513.
Following bariatric surgery, patients develop problems related to lax abdominal skin that may be addressed by contouring procedures. Third-party insurers have subjective requirements for coverage of these procedures that can limit patient access. The authors sought to determine how well third-party payers cover abdominal contouring procedures in this population.
The authors conducted a cross-sectional analysis of insurance policies for coverage of panniculectomy, lower back excision, and circumferential lipectomy. Abdominoplasty was evaluated as an alternative to panniculectomy. Insurance companies were selected based on their market share and state enrolment. A list of medical necessity criteria was abstracted from the policies that offered coverage.
Of the 55 companies evaluated, 98 percent had a policy that covered panniculectomy versus 36 percent who would cover lower back excision (p < 0.0001), and one-third provided coverage for circumferential lipectomy. Of the insurers who covered panniculectomy, only 30 percent would also cover abdominoplasty. Documentation of secondary skin conditions was the most prevalent criterion in panniculectomy policies (100 percent), whereas impaired function and secondary skin conditions were most common for coverage of lower back excision (73 percent and 73 percent, respectively). Frequency of criteria for panniculectomy versus lower back excision differed most notably for (1) secondary skin conditions (100 percent versus 73 percent; p = 0.0030), (2) weight loss (45 percent versus 7 percent; p = 0.0106), and (3) duration of weight stability (82 percent versus 53 percent; p = 0.0415).
For the postbariatric population, panniculectomy was covered more often and had more standardized criteria than lower back excision or circumferential lipectomy. However, all have vast intracompany and interpolicy variations in coverage criteria that may reduce access to procedures, even among patients with established indications.
减重手术后，患者会出现腹部皮肤松弛的问题，可通过整形手术来解决。第三方保险公司对这些手术的报销有主观要求，可能会限制患者的治疗选择。作者旨在确定在这类人群中，第三方支付者对腹部整形手术的报销情况如何。
作者对覆盖皮瓣切除术、下背部切除术和环形抽脂术的保险政策进行了横断面分析。评估了腹部整形术作为皮瓣切除术的替代方案。根据市场份额和州内参保人数选择保险公司。从提供覆盖范围的政策中提取了一套医疗必要性标准。
在评估的 55 家公司中，98%的公司有皮瓣切除术覆盖政策，而 36%的公司有下背部切除术覆盖政策（p < 0.0001），三分之一的公司提供环形抽脂术覆盖。在覆盖皮瓣切除术的保险公司中，只有 30%的公司也会覆盖腹部整形术。在皮瓣切除术政策中，最常见的标准是继发性皮肤疾病（100%），而在下背部切除术的覆盖政策中，最常见的标准是功能受损和继发性皮肤疾病（分别为 73%和 73%）。皮瓣切除术与下背部切除术的标准频率差异最大，主要体现在（1）继发性皮肤疾病（100%比 73%；p = 0.0030）、（2）体重减轻（45%比 7%；p = 0.0106）和（3）体重稳定持续时间（82%比 53%；p = 0.0415）。
对于减重手术后的患者，皮瓣切除术的覆盖范围更广，且标准更统一，而下背部切除术或环形抽脂术则不然。然而，所有手术都存在着公司内部和政策之间巨大的覆盖范围标准差异，这可能会限制手术的可及性，即使是对有明确适应证的患者也会如此。
