Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Macromastia.
Treatment: Breast Reduction (outpatient surgery -19318 x2).
The insurer denied: Breast Reduction (outpatient surgery -19318 x2).
The denial is overturned.

The patient is an adult female. The request is for bilateral breast reduction mammoplasty. Her current bra size is approximately 36DDD. She complains of recurrent chafing beneath her breasts. 
She states she has bilateral upper neck, shoulder and mid-back pain. She has undergone more than six months of PT (physical therapy) and acupuncture, without resolution of symptoms. She states her breast size has become discouraging and uncomfortable throughout her daily lifestyle. The patient's BSA (body surface area) of 1.73 square meters provided for a Schnur sliding scale score of 400 gm (grams). On physical examination, the patient evidenced bilateral pendulous breasts, macromastia, no scar, no masses, no nipple discharge, grade II/III ptosis. Her surgeon recommends bilateral breast reduction with the removal of 500 grams of breast tissue per side, which is in excess of the 400 grams predicted by the Schnur sliding scale.

The requested breast reduction is medically necessary.

Breast reduction surgery is medically necessary for this patient. She has the classic symptoms for macromastia, and medical treatments have not improved her symptoms. Her surgeon plans a reduction of at least 1,000 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 (6). 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 [Short Form-36], MPQ [McGill Pain Questionnaire], MBSRQ [Multidimensional Body Self Relations Questionnaire], and EuroQol [European Quality of Life questionnaire]. 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."
The American Society of Plastic Surgeons has published a national standard of care document regarding breast reduction. Based on aggregate high-quality evidence, the ASPS (American Society of Plastic Surgeons) 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 that she has significantly oversized 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.