Beyond the Hernia Repair: A Review of the Insurance Coverage of Critical Adjuncts in Abdominal Wall Reconstruction. Issue 12 (December 2020)

• Record Type: Journal Article
• Authors: Naga, Hani I.; Mellia, Joseph A.; Diatta, Fortunay; Othman, Sammy; Patel, Viren; Janis, Jeffrey E.; Heniford, B. Todd; Fischer, John P.
• Is Part Of: Plastic and reconstructive surgery. Volume 8:Issue 12(2020)
• Publication Date: 2020-12
• Subjects: Surgery, Plastic -- Periodicals; Surgery, Plastic -- Periodicals; Reconstructive Surgical Procedures -- Periodicals; 617.95205
• DOI: 10.1097/GOX.0000000000003309
• Languages: English
• ISSNs: 2169-7574

Abstract

Abstract : Background: The prevalence of complex abdominal wall defects continues to rise, which necessitates increasingly sophisticated medical and surgical management. Insurance coverage for reconstructive surgery varies due to differing interpretations of medical necessity. The authors sought to characterize the current insurance landscape for a subset of key adjunctive procedures in abdominal wall reconstruction, including component separation and simultaneous ventral hernia repair with panniculectomy (SVHR-P) or abdominoplasty (SVHR-A), and synthesize a set of reporting recommendations based on insurer criteria. Methods: Insurance companies were selected based on their national and state market share. Preauthorization criteria, preauthorization lists, and medical/clinical policies by each company for component separation, SVRH-P, and SVRH-A were examined. Coverage criteria were abstracted and analyzed. Results: Fifty insurance companies were included in the study. Only 1 company had clear approval criteria for component separation, while 38 cover it on a case-by-case basis. Four companies had clear approval policies for SVHR-P, 4 cover them on an individual case basis, and 28 flatly do not cover SVHR-P. Similarly, 3 companies had clear approval policies for SVHR-A, 6 cover them case by case, and 33 do not cover SVHR-A. Conclusions: Component separation and soft tissue contouring are important adjunctive AWR procedures with efficacy supported by peer-reviewed literature. The variability in SVHR-P and SVHR-A coverage likely decreases access to these procedures even when there are established medical indications. The authors recommend standardization of coverage criteria for component separation, given that differing interpretations of medical necessity increase the likelihood of insurance denials. Abstract : Supplemental Digital Content is available in the text.