
==== Front
Plast Reconstr Surg Glob Open
Plast Reconstr Surg Glob Open
GOX
Plastic and Reconstructive Surgery Global Open
2169-7574
Lippincott Williams & Wilkins Hagerstown, MD

GOX-D-24-00525
00029
10.1097/GOX.0000000000006147
3
Breast
Original Article
Timing of Pediatric Breast Reduction and Insurance Coverage: Single-institution Retrospective Study
Figueroa Ariel E. MD 1
Yau Alice MD 1
Lentskevich Marina A. MD 1
Termanini Kareem MD 1
Gosain Arun K. MD 1
From the Division of Plastic Surgery, Ann and Robert H. Lurie Children’s Hospital, Chicago, Ill.
Arun K. Gosain, MD, Division of Plastic Surgery, Lurie Children’s Hospital, 225 E. Chicago Avenue, Box 93, Chicago, IL 60611, E-mail: argosain@luriechildrens.org
9 2024
09 9 2024
12 9 e614715 5 2024
17 7 2024
Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Background:

Although long-term benefits of reduction mammaplasty have been proven, the appropriate age for adolescent reduction mammaplasty has been highly debated due to possible need for revision surgery. Practitioners often delay offering breast reduction to adolescents below age 18 based on presumed insurance denial. We reviewed trends in insurance denial at a single children’s hospital to analyze whether age and/or insurance carriers have a significant impact on coverage of breast reduction.

Methods:

A retrospective chart review from 2012 to 2022 of cisgender female patients with macromastia aged 12–20 years at the time of diagnosis was analyzed for differences in breast reduction insurance coverage based on age and body mass index at the time of diagnosis, referral to plastic surgery, and surgery.

Results:

A total of 121 cisgender women were included. There were no significant differences in the mean ages of patients who underwent breast reduction versus those who did not (16.46 years versus 16.96 years, respectively; P = 0.089), or in the mean body mass index for patients who did versus those who did not receive breast reduction (28.58 kg/m² versus 29.05kg/m², P = 0.382). Furthermore, there were no significant differences in the proportion of patients undergoing breast reduction by age (P = 0.200) or by insurance class (P = 0.403).

Conclusion:

Although insurance varies with carrier, the present findings suggest that surgeons need not delay in facilitating preauthorization for breast reduction in symptomatic patients presenting anytime during their teenage years.

OPEN-ACCESSTRUE
COUNTRYUNITED STATES
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pmcTakeaways

Question: Does age or insurance carrier have a significant impact on the coverage for reduction mammaplasty in adolescents under the age of 18?

Findings: Age, body mass index, and insurance carrier at the time of breast hypertrophy diagnosis do not have a significant impact on the timing of procedure completion or coverage for reduction mammaplasty in adolescents.

Meaning: Surgeons need not delay in facilitating preauthorization for reduction mammaplasty in adolescents presenting with breast hypertrophy anytime in their teenage years.

INTRODUCTION

Macromastia is benign breast hypertrophy, commonly associated with multiple physical and psychosocial ailments.1–8 Reduction mammaplasty is a very common plastic surgery procedure performed for macromastia with numerous cited benefits and sustained satisfaction years after surgery, with patients experiencing significantly improved pain, body image, and participation in physical activities.1–15 Although reduction mammaplasty is a widely accepted and effective treatment for adult women with macromastia, its use is debated in adolescent women.12,16–20 There are multiple etiologies for macromastia in adolescents, including juvenile mammary hypertrophy, adolescent macromastia, adolescent gigantomastia, obesity-related breast hypertrophy, and idiopathic causes.12,21–26 Regardless of the cause, macromastia is physically and psychologically debilitating for the developing teenage girl, resulting in back and shoulder pain, dermatitis of the inframammary folds, respiratory issues, unhealthy body image, and limitations on physical and sports activities.7,12,16,17,19,21,22,25,27,28

Although long-term benefits of reduction mammaplasty have been proven even in young macromastia patients, the appropriate age for adolescent reduction mammaplasty has been a highly debated topic due to the possible need for revision surgery, with a number of insurance companies reportedly imposing arbitrary age restrictions and inconsistent criteria for surgery.28–32 In addition to requiring the patient to be 18+ years of age, some insurance policies require trial periods during which the symptomatic patient must first undergo conservative treatment with weight loss and physical therapy of varying durations before even being considered for reduction mammaplasty, a barrier resulting in many patients being lost to follow-up and failing to receive appropriate, safe treatment.29,31,32

Long-term follow-up studies show significantly higher satisfaction scores with body image and physical well-being compared with normative data, demonstrating that initial reduction mammaplasty effectively provides therapeutic relief, despite potential for breast regrowth and low risk for secondary mammaplasty.12,17,19,28 Although it is well-documented that reduction mammaplasty has long-lasting benefits in symptomatic adolescent patients with macromastia, the rate of insurance coverage for reduction mammaplasty performed before the age of 18 years has not previously been reviewed. Due to lack of information on insurance coverage for these patients, practitioners often choose to delay offering breast reduction to adolescents below the age of 18 due to a presumption that insurance would not cover surgery for these patients. To address this gap in knowledge, we reviewed trends in insurance denial at a single children’s hospital to analyze whether age and/or insurance carriers have a significant impact on coverage of breast reduction, as well as the current requirements for preauthorization for reduction mammaplasty across various insurance policies. We hypothesized that insurance approval would preferentially be granted for older patients.

METHODS

Approval was obtained from the institutional review board of a large urban children’s hospital to perform a retrospective chart review from 2012 to 2022 of cis-gender female patients with macromastia aged 12–20 years at the time of diagnosis. The following information was collected: age at the time of diagnosis, age at the time of plastic surgery procedure, patient’s body mass index (BMI), whether the patient received breast reduction treatment (CPT code 19318), whether insurance covered the treatment, and whether the hospital covered the treatment in cases of insurance denial. Information on insurance financial classes was collected according to the hospital Business Analytics’ categorization of insurance payors. Finally, publicly available insurance policy information for reduction mammaplasty from a wide range of private and public insurers was collected and compared. Data were collected onto a password-protected Excel spreadsheet for data analysis. Average age and SD at diagnosis and age at procedure completion were calculated. Chi-squared tests, t tests, and Fisher exact tests were performed using IBM SPSS Statistics software, analyzing significant differences in insurance coverage of breast reduction based on age and BMI at the times of diagnosis, referral to plastic surgery, and surgery.33

RESULTS

A total of 121 cisgender women aged 12–20 years were diagnosed with hypertrophy of the breast from 2012 to 2022. Women diagnosed with breast hypertrophy were between 12 and 18 years of age, of whom 17 (14%) were in the 12–14 age group, 77 (64%) were in the 15–17 age group, and 27 (22%) were in the 18–20 age group. Average age at diagnosis was 16.34 years ± 1.58. Seventy (56%) of these patients were referred to pediatric plastic surgery for reduction mammaplasty, out of whom 47 (67%) underwent breast reduction (unilateral = 1, bilateral = 44, unknown = 2; Table 1). Among women who received reduction mammaplasty (age 14–20 years), average age at procedure completion was 17.15 years ± 1.54. BMI for patients referred to pediatric plastic surgery ranged from 19.64 to 44.69 kg per m2, with 39 of 70 (56%) patients covered by private insurance and 31 of 70 (44%) covered by Medicaid or an equivalent health insurance plan at the time of diagnosis (Table 2). Amount of breast tissue resected ranged from 276 to 7148 g.

Table 1. Number of Patients Per Age Group at Times of Diagnosis, Referral to Pediatric Plastic Surgeon, and Whether Breast Reduction Was Completed

Age Groups	No. Patients Diagnosed with Breast Hypertrophy	No. Patients Referred to Pediatric Plastic Surgeon	Breast Reduction Done	
Yes	No	P	
12–14	17	6	6	0	0.200	
15–17	77	47	30	17	
18–20	27	17	11	6	
Total	121	70	47	23	
Chi-square analysis showing no difference between age of patient and breast reduction.

Table 2. Distribution of Patients Undergoing Breast Reduction by Insurance Financial Class at the Time of Diagnosis

Insurance Financial Class at the Time of Diagnosis*	Breast Reduction Done?	P	
Yes	No	
Blue Cross	19	7	0.403	
Commercial	5	4	
Managed care	1	3	
Medicaid	5	1	
Medicaid managed care	8	3	
Medicaid replacement	9	5	
Total	47	23	
Chi-square analysis showed no difference between insurance type and breast reduction.

* Information on insurance financial class was collected according to LCH Business Analytics’ categorization of insurance payors.

The greatest number of patients were diagnosed and had the procedure performed between ages 15 and 17 (Table 1). Two patients (4%), both 16 years of age at diagnosis, were self-pay; three (6%) patients who were 14, 15, and 16 years of age at time of diagnosis had their procedures covered by philanthropic funds; and 37 (79%) patients’ procedures were covered by insurance. Five (11%) of the patients with breast hypertrophy evaluated for reduction mammaplasty were preauthorized by insurance, but had their procedure performed outside of our institution. Amount of breast tissue resected positively correlated with the patient’s preoperative BMI (R2 = 0.516, P < 0.001), with an average amount of breast tissue removed for cases of bilateral reduction mammaplasty of 1776.64 g (Fig. 1). There were no significant differences in mean ages of patients who underwent breast reduction versus those who did not (16.46 years versus 16.96 years, respectively; P = 0.089), or in mean BMI for patients who did versus those who did not receive breast reduction (28.58 kg/m2 versus 29.05 kg/m2, P = 0.382) at the time of diagnosis. When average preoperative BMI was analyzed by age groups for patients who did versus did not receive breast reduction, the differences remained insignificant (Fig. 2). Furthermore, there were no significant differences in the proportion of patients undergoing breast reduction by age (Table 1; P = 0.200) or by insurance class (Table 2; P = 0.403) at the time of diagnosis.

Fig. 1. Scatter plot of amount of breast tissue removed (g) based on preoperative BMI (kg/m2) (P < 0.001).

Fig. 2. Differences in mean preoperative BMI (kg/m2) for patients who did (blue) vs did not (red) have breast reduction by age group (age group 15–17 years: P = 0.099; age group 18–20 years: P = 0.241).

Publicly available insurance policies for reduction mammaplasty were reviewed (Table 3). Of those, 42% listed requirements for patients younger than 18 years of age, which included complete or stable breast growth for at least 6 months. In total, 83% of insurance policies required a minimum weight of breast to be removed, and 83% required conservative treatment trial ranging from 6 weeks to 6 months. Three policies required ideal body weight, and two stated that reduction mammaplasty for psychological reasons does not count as a symptom for insurance coverage.

Table 3. Overview of Insurance Coverage Requirements for Reduction Mammaplasty in Adolescents

Provider	Type	Age Requirement >18 y	Requirements for <18 y	Requires Minimum Breast Weight to Be Removed	Requires Conservative Treatment Trial	Other Notes	
Aetna	National	Y	Breast size stable for 1 y	Y	Y (3 mo)	Skin conditions only count as symptoms for coverage if not responsive to dermatological treatments	
Anthem	National	N		Y	Y (3 mo)		
Centene	National	Y	Tanner stage V, and no change in breast cup size in 6 mo	Y	Y		
Cigna	National	Y	Completed breast growth	Y	Y	Reduction mammoplasty for psychological effects does not count for coverage	
Highmark	National	Y	To be discussed on an individual basis	Y	Y (3 mo)		
United Healthcare	National	N		N	N		
BCBS FEP	Federal	N		Y	Y (6 wk)	Individual must be within 20% of IBW	
Medicare/ Medicaid/ Managed Care	Federal	N		Y	Y (6 mo)	Conservative measure includes “correction of obesity”	
BCBS Calif.	State	N		Y	Y (6 wk)	Individual must be within 20% of IBW	
BCBS Illi.	State	N		N	N	Reduction for psychological reasons does not count for coverage	
BCBS Fla.	State	N		Y	Y (6 wk)		
BCBS Mass.	State	Y	Documented Tanner stage IV or V and stable height and weight measurements for 6 mo	Y	Y (6 wk)		
N indicates no stated requirement on insurance information.

DISCUSSION

Reduction mammaplasty is a common surgical procedure to alleviate distressing physical and psychosocial symptoms of macromastia. We hypothesized that insurance companies may impose strict age restrictions for reduction mammaplasty in adolescents under age 18, which would delay surgery for patients with symptomatic macromastia. Findings from our single-institution study show that age, BMI, and insurance carrier at diagnosis do not play a role in timing or coverage of breast reduction procedures in adolescents. Therefore, our findings suggest that surgeons need not delay in facilitating preauthorization for breast reduction in symptomatic adolescent patients, as each insurance company will request some variation of the standard criteria for breast reduction irrespective of age.

Reduction mammaplasty is a prevalent surgery performed in cases of macromastia.1–15 However, timing of surgery in adolescents remains controversial.28–32 Before completing the present review, the senior author would often encourage patients who presented with symptomatic macromastia to wait until age 18 to request preauthorization from their insurance carriers due to preconceptions that insurance carriers would likely deny this request in patients under age 18 years. The presumption that breast reduction for patients under age 18 is less likely to be covered by insurance carriers has been reflected by prior authors, and Nuzzi et al suggested that the arbitrary nature of age restrictions on reduction mammaplasty imposed by care providers and insurance payors is to the patient’s detriment.19 However, among our patient cohort, there were fewer self-pay patients than expected, and patients who received the surgery were neither significantly older nor did they have significantly higher BMI than patients who did not receive surgery.

Among the insurance policies studied, we found the requirements for preauthorization for reduction mammaplasty to be variable and inconsistent with the American Society of Plastic Surgeons’ (ASPS) recommended criteria, as has been explored in previous literature.28–32 The ASPS recommends demonstration of two clinical symptoms as a result of breast hypertrophy, regardless of body weight and breast size for approval of reduction mammaplasty as first-line therapy. In contrast, insurance companies’ requirements involve some variation of general criteria including a range of ambiguous descriptions to three or more symptoms being required, a trial of nonoperative therapy (eg, supportive bras, lotions for intertriginous rashes), and a strong preference for resection weight volume measurements, citing the Schnur scale.34 The Schnur scale assigns a weight of breast tissue to be removed based on body weight and surface area. One study showed that when the resected weight was lower than the insurance’s minimum stated predicted amount, based on the Schnur scale, insurance was denied among adult patients. Unfortunately, the Schnur scale was created based on an adult population and may not accurately predict adolescent breast reduction weights for all patients.35 Furthermore, criteria for resection weight is the most commonly reported criteria requirement for insurance approval; therefore, regardless of an adolescent patient’s age, if this requirement is not fulfilled one can expect insurance rejection. In Boyd’s study exploring national trends of insurance denial reduction mammaplasty, it was found that inconsistent insurance policies lead to inconsistent preauthorization rates and that even though specific criteria were met, physicians often had to appeal for approval more than once.36 In our review, less than half of insurance carriers have listed requirements for adolescent patients seeking reduction mammaplasty which raises concerns regarding preauthorization inconsistencies, and ultimately, inefficient and delayed care for patients.32,37–40 To illustrate, although insurance type was not a significant factor for reduction mammaplasty procedure being completed, there remained a significant portion of patients (40% of patients in the 15–17 and 40% of the 18–20 age group) who did not receive reduction mammaplasty due to insurance denial. Additionally, 10% of cases were conducted due to self-pay or institutional funds, a resource not widely accessible to all young women with macromastia.29 However, with improved advocacy, reduction mammaplasty can become increasingly accessible as demonstrated in the study by Kimia et al.29 Preauthorization rates for reduction mammaplasty among adolescents were shown to increase after Pennsylvania Medicaid changed its policy to reflect that of ASPS’ recommendations in 2015, which was likely followed by private insurers.29

Reluctance to pursue reduction mammaplasty in young women still exists among plastic surgeons, referring physicians, and patients’ families, although exact trends are not reported.41,42 We were able to show that in the 12–14 age range, only 35% of patients with breast hypertrophy were referred to plastic surgeons, compared with the 61% referred in the 15–17, and 63% in the 18–20 age range. Reasons for this remain to be explored, and provide another challenge for adolescent patients desiring care. Known concerns regarding reduction mammaplasty in the adolescent population include recurrent breast hypertrophy, altered breast or nipple sensation, and inability to lactate in the future.43,44

Although etiologies of breast hypertrophy may be unclear and unpredictable, denying young patients breast reduction surgery solely based on their age may be detrimental to their well-being, accompanied by social embarrassment, peer harassment, avoidance of athletic activities, neck and back pain, and disordered eating behaviors.12,27 In contrast, several studies have shown that young reduction mammaplasty patients have excellent quality of life following reduction mammaplasty in the areas of breast satisfaction, and sexual well-being.12,17,19,28 Additionally, none of the 47 patients from our 10-year retrospective study have required a repeat reduction mammaplasty. Anecdotally, adolescents who have undergone breast reduction for symptomatic macromastia are among the most gratified patients in the senior author’s practice. Previous studies have shown revision rates to be very low in the adolescent population. In a systematic review of 2926 adolescent patients, 18% experienced some degree of postoperative breast regrowth, with a revision rate of 2.7%.20 In another study of 446 patients, 27 (6.05%) patients noticed breast regrowth 1-year postoperatively, with six (1.3%) patients undergoing revision.19 Regarding altered breast or nipple sensation, of the over 500 patients who underwent reduction mammaplasty, less than 9% had persistent altered breast or nipple sensation after the first postoperative year.43 Furthermore, Cruz’s study on breastfeeding patterns after reduction mammaplasty showed that regardless of the reduction mammaplasty pedicle pursued, there was no difference in breastfeeding compared with women with macromastia who had not undergone reduction mammaplasty.44

More helpful factors for surgeons to consider when selecting appropriate patients for reduction mammaplasty are the individual patient’s obesity status and time since menarche and thelarche.6,9,19,25,45–49 Although previous studies show that higher BMI does not correlate with increased rates of complications or poorer satisfaction outcomes,10,46 other studies demonstrated that BMI, combined with onset of puberty, is a predictor of adolescent breast size stability and potential for breast regrowth with need for revision surgery.12,19,45,46 Previous studies show that higher BMI is associated with earlier thelarche and more advanced breast development.45,48,49 Findings from one study demonstrated that breast size takes longer to stabilize in obese patients, and recurrence of breast hypertrophy is also more likely if reduction mammaplasty is performed less than 6 years after menarche for obese patients compared with 3 years in normal-weight patients.19 Additionally, earlier menarche was correlated with more severe hypertrophy, and obese patients underwent thelarche and menarche earlier than normal-weight patients.19 Optimal reduction mammaplasty outcomes are generally achieved once breast size has been stable for 6–12 months, indicating the patient should be considered for reduction mammaplasty once breast size has stabilized regardless of age or BMI.12,50

Limitations of our study include it being limited to the experience of a single large children’s hospital, lack of consistent information on BMI, and inconsistent insurance requirements for coverage of breast reduction. Data on BMI can help better characterize etiologies of macromastia of our patient population and provide information on whether reduction mammaplasty is effective in reducing BMI in the long term. Furthermore, understanding why not all pediatric patients are referred to pediatric plastic surgeons when breast hypertrophy is diagnosed may spur solutions to prevent delay in breast hypertrophy care. Lastly, quantifying insurance approvals and denials across a national level would help to better understand why the pediatric population is often rejected for reduction mammaplasty.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

Published online 9 September 2024.

Disclosure statements are at the end of this article, following the correspondence information.
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