From the Division of Plastic Surgery, Department of Surgery, School of Medicine; the Department of Biochemistry and Molecular Biology; and the Department of Preventative Medicine and Community Health, University of Texas Medical Branch.
Plast Reconstr Surg. 2020 Aug;146(2):127e-136e. doi: 10.1097/PRS.0000000000006968.
Reduction mammaplasty is the standard of care for symptomatic macromastia. The process of requesting insurance coverage for reduction mammaplasty is cumbersome and potentially controversial, and insurance policies vary significantly. The goal of our analysis is to identify trends in insurance coverage rates, assess for the presence of disparities, and propose ways to increase chances of successful preauthorization.
The authors performed a retrospective review of preauthorizations for reduction mammaplasty at a single institution from 2012 to 2017. Insurance company names were deidentified. Preauthorization denial rates were assessed by year, insurance carrier, and reason for denial. Multiple regression analysis was performed to identify predictors for predetermination denial by insurance companies.
Among 295 preauthorizations, 212 were approved (72 percent) and 83 were denied (28 percent), among which 18 were appealed, 13 successfully. Rates of insurance denials have been increasing steadily, from 18 percent to 41 percent. Medicaid had the lowest denial rates (9.3 percent), whereas private carriers denials ranged from 21.4 to 62.1 percent. In terms of reason for denial, 30 percent were because of contract exclusion, 39 percent were because of inadequate documentation or not meeting medical criteria, and 12 percent were because of inadequate predicted resection weight. Certain private insurance carriers were the only independent predictors of predetermination denial.
Rate of preauthorization denials is high and has been increasing steadily. Insurance criteria remain arbitrary. A proper documentation and appeal process by the plastic surgeon may improve rates of insurance approval. Although resection weight does not correlate with symptom relief, predicted breast tissue resection weight continues to be critical for insurance approval.
缩乳术是治疗巨乳症症状的标准方法。申请缩乳术保险的过程繁琐且存在潜在争议，而且保险政策差异很大。我们分析的目的是确定保险覆盖范围率的趋势，评估是否存在差异，并提出增加成功预授权机会的方法。
作者对 2012 年至 2017 年在一家机构进行的缩乳术预授权进行了回顾性研究。保险公司的名称被匿名化。按年份、保险公司和拒绝原因评估预授权拒绝率。进行多元回归分析以确定保险公司预判定拒绝的预测因素。
在 295 份预授权中，212 份获得批准（72％），83 份被拒绝（28％），其中 18 份被上诉，13 份成功。保险拒签率稳步上升，从 18％上升到 41％。医疗补助的拒签率最低（9.3％），而私人保险公司的拒签率在 21.4％至 62.1％之间。就拒绝原因而言，30％是因为合同排除，39％是因为文件不足或不符合医疗标准，12％是因为预计切除的重量不足。某些私人保险公司是预判定拒绝的唯一独立预测因素。
预授权拒绝率很高，且一直在稳步上升。保险标准仍然是任意的。整形外科医生进行适当的文件和上诉程序可能会提高保险批准率。尽管切除重量与症状缓解无关，但预测的乳房组织切除重量仍然是保险批准的关键。
