Regional Variation in Reimbursement for Reduction Mammaplasty: A Claims-Based Analysis Across the United States.

BACKGROUND: Numerous factors contribute to the preoperative planning and coverage determination of reduction mammaplasty. Insurer guidelines, determination of medical necessity, and mathematical models for resection volume are only a few examples that are well studied. However, identifying regional patterns in payer amounts for reduction mammaplasty requires further exploration and can inform health care access and policy interpretation. The purpose of this study is to examine regional variation in reimbursement values for reduction mammaplasty across the United States. METHODS: The PearlDiver Mariner insurance claims database was used to extract records for female patients who underwent reduction mammaplasty (CPT 19318) between 2010 and 2023. A total of 11,670 records were analyzed by insurance payer-type among 4 United States census-defined regions (Northeast, Midwest, South, and West). RESULTS: The US South had the lowest reimbursement value for reduction mammaplasty, with an average of $3426.6 per record. The West demonstrated the highest reimbursement value, with an average of $4550.22 per record. The West also demonstrated the greatest amount of interstate variability within a region ($7049.89 per record). When stratified by payer type, private insurers contributed to the majority of claims and reimbursed at higher rates compared with public insurers across all regions. CONCLUSIONS: State and regional differences exist in payer reimbursement for reduction mammaplasty in the United States. The West had the highest and most variable reimbursement values, while the South had the lowest reimbursement values. Understanding regional variability in insurance coverage can facilitate discussions regarding regional and payer-based payment structures and access to care.

Duke Scholars

Author Detlev Erdmann Surgery, Plastic, Maxillofacial, and Oral Surgery