Comparing coverage of medically indicated reduction mammoplasty among Swiss health insurers: a retrospective study.

[BACKGROUND] Reduction mammoplasty is commonly used to treat macromastia, highlighting the need to address the physical and psychosocial issues associated with breast hypertrophy. However, clear inconsistencies in insurance coverage and varying criteria for medically necessary surgery are evident. The compliance of Swiss insurance companies with the 2019 recommendations of the Swiss Society of Medical Officers and Insurance Physicians has not been fully assessed.

[AIM] This study aimed to investigate the proportion and variability in cost approvals for reduction mammoplasty among Swiss insurers, focusing on differences in their approval and denial rates.

[METHODS] A retrospective study was conducted on patients presenting with breast disease at Spital Thurgau AG between January 2016 and December 2022. It analysed the proportion and variability in cost approval rates for reduction mammoplasty among different insurance providers. Demographic patient data were collected and statistically analysed using chi-squared and Fisher's exact tests to evaluate if a statistically significant relationship exists between insurance providers and cost approval. Only Swiss insurance providers servicing at least five patients in the final cohort were included.

[RESULTS] Between January 2016 and December 2022, 1105 patients with breast disease were evaluated at Spital Thurgau AG, of whom 210 were eligible for this study on reduction mammoplasty cost approvals. Of the 210 cost approval requests made to nine different insurance companies, 54% were approved. Approval rates differed significantly among insurers (p = 0.003).

[CONCLUSION] This study uncovered an elevated rate of cost approval denials, which depended significantly on the insurance provider. To ensure that the costs of a medically indicated breast reduction are covered consistently and fairly, a review of existing guidelines and their implementation is necessary to improve the system.