Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 31-year-old female who complains of back, shoulder, neck and rib pain. She has shoulder grooving. The physician reviewer found that the American Society of Plastic Surgeons (ASPS) states that reduction mammaplasty authorization should be based on documentation of the severity of the symptoms of macromastia and impact on health-related quality of life with at least two of the following signs: chronic breast pain due to weight of the breasts; intertrigo unresponsive to medical management; upper back, neck, and shoulder pain; backache, unspecified; thoracic kyphosis, acquired; shoulder grooving from bra straps; upper extremity paresthesia due to brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area; headache; and congenital breast deformity.
This patient reports back, shoulder and neck pain, with shoulder grooving documented on physical examination. There is no report of chronic breast pain due to weight of the breasts, intertrigo unresponsive to medical management, thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. Because there are at least two quality of life signs, the requested service would be considered medically necessary according to ASPS criteria.
The American Society of Plastic Surgeons (ASPS) has indicated the decision to perform reduction mammaplasty should be based on the patientas symptoms and a surgeonas assessment of the likelihood of benefit as opposed to the amount (weight) of breast tissue to be removed. It has been indicated by others, however, that the ASPS position is largely based on observational studies, which are un-blinded, lack randomized control groups and have potential for selection bias, and expert opinion. The more common and accepted guidelines use a measurement of body surface area and weight removed to determine medical necessity.
The gold standard for this determination is the study by Schnur and colleagues. This article does not establish a defined lower weight for breast resection; it establishes a range. According to the article, 351 grams would be the lower 22nd percentile of weight resection for a BSA of 1.67, with 224 grams being the lower 5th percentile of weight of resection with a BSA of 1.67. According to the article, aif the womanas data plot above the 22nd percentile, her motivation is purely medical. If her data plot below the 5th percentile, her motivation is purely cosmetic. If her data plot between the two lines, her motivation is mixed and must be looked at individually.a
In this patient, the proposed resection of approximately 338 grams per breast is essentially at the 22nd percentile of 351 grams per breast at a BSA of 1.67 and would qualify the procedure as medically necessary according to weight. Combining this determination of medical necessity based on weight with the determination of medical necessity based on ASPS criteria, the requested service of bilateral reduction mammaplasty would be considered medically necessary for this patient.
The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) To improve function; (2) To create a normal appearance, to the extent possible.
This patient complains of back, shoulder and neck pain with rib pain. She has shoulder grooving from the weight of her breasts on her bra straps. She has taken muscle relaxers and anti-inflammatory drugs, without relief. She has tried many sessions of physical therapy for upper back pain and has undergone chiropractic treatment without relief. She has breast hypertrophy, which is a developmental abnormality. She has a functional disability from pain, and breast reduction surgery would be to improve function. The California reconstructive surgery statute applies, and breast reduction surgery would constitute reconstructive surgery as defined by the California reconstructive surgery statute.