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Breast reconstruction and medical necessity.

Is postmastectomy breast reconstruction medically necessary? Currently, there are paradoxical answers to this question. The explicit answer is ‘‘yes.’’ Breast reconstruction has been associated with improved quality-of-life measures, including enhanced self-esteem and positive body image, in women receiving such procedures after initial mastectomy treatment of cancer. The implicit answer, however, is ‘‘no.’’ While specialty plastic surgeons have preached the medical necessity of breast reconstruction, the specialty’s practice has diverged from its own gospel apparently on an economic basis. A brief review of recent publications outlines actual current practices of breast reconstruction. Discussion of breast reconstruction options is less frequently offered to uninsured patients compared with insured patients. Subsequently, referrals for breast reconstruction can be 5 times higher for patients with private insurance than patients with Medicare or Medicaid coverage. Between 1998 and 2007, the actual rate of postmastectomy patients undergoing breast reconstruction increased from 13.3% to 25.6%, but ‘‘ Ithose [patients] with private or managed care insurance were more than twice as likely to undergo breast reconstruction as those with Medicare, Medicaid, or no insurance....’’ In practice, therefore, each stage of breast reconstruction, including discussion, referral, and application, is disproportionately available to wealthier, insured patients. How does medical necessity apply to this pattern of practice? The hypocrisy of this set of circumstances is obvious. The relative application of breast reconstruction to economically favored groups, however, has operational implications. If insurance and reimbursement regulation evolve to ever more strict demands for outcome justifications, how can the medical necessity of breast reconstruction be defined amidst such a disparity of practice? Economically selective practice of postmastectomy breast reconstruction places the specialty of plastic surgery in a weakened position in the promotion of breast reconstruction. As a matter of its own ethics and concerns for insurance evolution, the specialty of plastic surgery should work toward the elimination of economically based unequal access to breast reconstruction. Such a position need not be quixotic or fiscally crippling. Evidence exists to show that patients with low incomes and poor or no insurance coverage take equal advantage of and benefit from breast reconstruction procedures compared with patients with higher incomes and private insurance. Other studies demonstrate how defined patient groups with diverse pay or mixes can be productively organized into financially sustainable practices. Disparity in the application of breast reconstruction is itself an unsustainable practice. Plastic surgeons performing breast reconstruction, especially in such high-profile practices as cancer centers and university hospitals, should take every opportunity to fully apply the definition of medical necessity to breast reconstruction for the benefit of patients and the integrity of the specialty.