Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Back, neck and shoulder pain.
Treatment:  Surgery - Reduction Mammoplasty (19318x2).

The insurer denied the surgery.  The denial is overturned. 

Yes, the Reduction Mammoplasty (19318x2) is medically necessary.

The patient is a female.  She complains of back, neck and shoulder pain due to her large breasts.  Her symptoms have been present for years.  Her symptoms have not improved with chiropractor care or massage therapy.  Her BSA (body surface area) is 2.03 m2.  Her surgeon recommends bilateral breast reduction with the removal of 750 grams of tissue from each breast.

Breast reduction surgery is medically necessary for this patient.  She has the classic symptoms for macromastia, and medical treatments including massage and chiropractor adjustments have not improved her symptoms.  Her surgeon plans a reduction of at least 750 grams of tissue total.  Symptomatic macromastia is a mechanical problem, and conservative treatments have been shown to be ineffective for this condition.  Non-operative treatments are unlikely to improve her pain, and surgery provides the only real chance for symptomatic relief.    

The best paper on this topic is by Collins and Kerrigan.  This report is based on data from the BRAVO (Breast Reduction Assessment of Value and Outcomes) study that prospectively followed 243 patients with symptomatic macromastia.  The following is quoted directly from this article:
"Breast hypertrophy has a significant impact on women's health status and quality of life as measured by validated and widely used self-report instruments including the SF-36, MPQ, MBSRQ, and EuroQol.  In women presenting for surgery, nonsurgical measures including weight loss, physical therapy, special brassieres, and medications were not effective in providing permanent relief of breast-related symptoms.  In contrast, both pain and overall health status were markedly improved by breast reduction, essentially restoring functional status to that of age-matched norms." 

A study by Scholtz et al confirms the paucity of benefits from conservative therapy.  According to the authors, "Macromastia causes back and neck pain, scaphodynia, intertrigo of the inframammary crease up to dysesthesia.  Typical complaints of patients with macromastia are physical burden, psychological irritation and aesthetic deformity, often resulting in social isolation.  Despite the demonstrable success of reduction mammaplasty to eliminate not only the symptoms of macromastia but the cause of the ailment, conservative therapy is still favored by insurance companies.  Conservative treatments do not eliminate the causes of the illness." 

A 2014 study by Strong and Hall-Findlay concluded, "We found that reduction mammaplasty has a positive impact on a range of symptoms, even with lower volume resections and regardless of body surface area-calculated adjustments.  This adds further weight to the argument that patients should not be denied access to the surgery based on arbitrary volume restrictions.  We advocate freedom for the surgeon to make a decision on potential benefits of surgery based around the needs of each individual patient." 

The patient has large pendulous breasts with shoulder grooving and the classic symptoms for macromastia.  Breast reduction is the only treatment that is proven in the medical literature to be curative for symptomatic macromastia, and hundreds of peer-reviewed studies confirm the benefit of breast reduction surgery for women with upper torso pain due to breast hypertrophy.  Non-operative treatments are unlikely to improve her pain, and surgery provides the only real chance for symptomatic relief.