The Insurance Coverage of Otoplasty and the Surgical Management of Prominauris in the United States
Michael Ha1, Ledibabari M. Ngaage1,2, Beita Badiei1, Chinenye Onyima1, Joshua S. Yoon3, Arthur J Nam3, Erin M Rada1, Yvonne M. Rasko1
1Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, 2Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, 3Division of Plastic Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
Background: Protruding ears, or prominent ears, are the most common congenital deformity of the head and neck, effecting up to 5% of the population. From an early age, it is often associated with peer ridicule, leading to social and psychological concerns at a critical time of social development. It can be addressed with an otoplasty, which is often considered a cosmetic procedure. However, with significant deviation from expected anatomy, it may be defined as “reconstructive” for normal approximation. The authors assessed insurance coverage of otoplasty and its medically necessary criteria.
Methods: We conducted a cross-sectional analysis of 58 insurance policies for otoplasty. The insurance companies were selected based on their state enrolment and market share. A Web-based search and telephone interviews were utilised to identify the policies. Medically necessary criteria were then abstracted from the publicly available policies.
Results: Of the 58 insurance policies assessed, 25 (43%) would consider coverage of an otoplasty. There were two indications for coverage: hearing loss (n = 20, 80%) and normal approximation (n = 11, 44%). Hearing loss was a covered indication for significantly more insurers than normal approximation (80% vs 44%, p 20mm from the temporal surface of the head (n = 2, 100%).
Conclusion: Reconstructive surgery is the correction of abnormal structures of the body to either improve function or to approximate a normal appearance. However, in the insurance coverage of otoplasty, there is a great discrepancy in how this is implemented. We thus encourage plastic surgeons to challenge the distinction between “cosmetic” and “reconstructive” surgery by insurance companies.
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