Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Macromastia
Treatment: Outpatient bilateral breast reduction
The insurer denied coverage for outpatient bilateral breast reduction.
The denial is overturned.

The patient desires breast reduction. The patient states that they have always been large breasted but has gained weight during the pandemic and then lost the weight and states their breasts have remained approximately a DDD cup size for the past 2 years. The patient states they have back, neck and shoulder pain on a daily basis which they state they do not treat and just deals with the pain. The patient states they have a rash and irritation under their breasts which is constant, and they treat this with skin moisturizer. The patient states this is worse in the summer months but is constant. The patient has done yoga for the past two years which they state helps temporarily with their back, neck and shoulder pain. The patient has also started physical therapy as recommended by their provider which they state has also only helped temporarily. The patient would like to be made to as smallest size as possible. Family history is weakly positive with patient's paternal grandmother having had breast cancer. The patient is 5 feet 8 inches tall and weighs 130 pounds. A breast examination reveals bilateral breast hypertrophy consistent with DDD cup size, question right breast larger than left. Nipple position is 28 centimeters (cm) from the sternal notch left, 29 cm from the sternal notch right. The inframammary fold is 24.5 cm left, 25.5 cm right. Nipple to fold distance is 14 cm left, 12 cm right. Breast examination reveals homogeneous breast parenchyma without dominant mass, skin or nipple retraction. The procedure code is 19318 bilateral. Estimated breast weight is 800-900 grams (g) each. The patient's surgeon anticipates removal of 400-500 g per breast. 

Breast reduction is medically necessary for this patient and is the only curative treatment for their pain.

Breast reduction surgery is medically necessary for this patient. The patient has the classic symptoms for macromastia, and medical treatments have not improved their symptoms. The patient's surgeon plans a reduction of at least 800 to 1000 g 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 the patient's pain, and surgery provides the only real chance for symptomatic relief. The best paper on this topic is by Collins and Kerrigan. [1] 

The American Society of Plastic Surgeons (ASPS) has published a national standard of care document regarding breast reduction. Based on aggregate high-quality evidence, the ASPS work group "recommends that post menarche female patients presenting with breast hypertrophy should be offered reduction mammaplasty surgery as first line therapy over non-operative therapy based solely on the presence of multiple symptoms rather than resection weight." The patient has large pendulous breasts with shoulder grooving and the classic symptoms for macromastia. Photos show a patient with stooped shoulders, forward posture, bra strap grooving with ulcerations and pendulous large breasts. 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 the patient's pain, and surgery provides the only real chance for symptomatic relief. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for outpatient bilateral breast reduction is substantiated.