Cost and insurance coverage for reduction mammoplasty: Evidence from United States claims data

Despite the proven benefits of reduction mammoplasty, the procedure is often denied by insurance plans even when deemed medically beneficial. The present study sought to evaluate nationwide variation in insurance type coverage, as well as out of pocket and total costs for reduction mammoplasty in outpatient settings.

The Truven MarketScan Database was analyzed to identify patients who underwent reduction mammaplasty (CPT 19318) in an outpatient setting in 2021. Total and out-of-pocket (OOP) expenses, as well as cost variation between the regions and insurance plan types were assessed. Univariate parametric analysis was applied to evaluate the variation in financial variables.

In total, 8660 patients underwent reduction mammoplasty. The overall median OOP cost was $523 (IQR $1548) and total payment cost was $8097 (IQR $8245). OOP medians did not vary by region (p=0.016) but varied by insurance type (p<0.001) with the highest cost paid with high-deductible health plan (HDHP) ($1164, IQR $2196) and lowest with point of service with capitation (CPOS) ($25, IQR $852). For total cost expenses, there was statistical significance for region and plan type (p<0.001). With the highest median total costs in Northeast region ($11023, IQR $11324) and point of service (POS) ($9923, IQR $11536).

Patients undergoing reduction mammoplasty may incur high OOP costs with a HDHP plan. Although out-of-pocket cost did not vary by region, it varied with the insurance type. Insurance companies are becoming increasingly involved in determining the medical necessity of surgical procedures and should be aware of the financial burden placed on patients.