Integrated health original article Insurance coverage for massive weight loss panniculectomy: a national survey and implications for policy

Background: Current panniculectomy coverage guidelines are developed by insurance companies, and surgeons have limited input as to what policies are fair to physicians and patients. In this study, for the first time, plastic surgeons were surveyed nationally to determine their opinions on which coverage criteria are clear, reasonable, and accessible. Objectives: The objective of this study was to compare how frequently insurance companies use panniculectomy coverage criteria versus how favorably plastic surgeons assess these criteria. Setting: United States plastic surgery practices. Methods: Panniculectomy coverage criteria were compiled from third-party payors nationally. A survey using these criteria to assess the clarity, accessibility, and reasonability of each criterion was created and distributed to all members of the American Society of Plastic Surgeons. Results: According to survey responses from plastic surgeons, the highest ranking criteria for panniculectomy coverage were “Patient is weight stable for at least 6 months” and “Patient must be at least 18 months post–bariatric surgery.” These criteria were required by only 41.3% and 39.7% of insurance providers, respectively. The most common requirement for insurance coverage was “Chronic maceration of skin folds with failure to respond to at least 3 months of treatment with oral or topical medication.” This was necessary for coverage by 81% of insurance providers, yet plastic surgeons ranked this criterion 12th of 17 criteria. Conclusions: Here we present a physician assessment of insurance criteria for the coverage of panniculectomy. Given the discrepancy between how favorably a criterion is scored by plastic surgeons and how frequently it is required by third-party payors for coverage, we conclude that more physician involvement in the development of insurance coverage guidelines would be beneficial. (Surg Obes Relat Dis 2016;12:412–416.) r 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved.