Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Symptomatic macromastia. 
Treatment: 19318-Reduction Mammaplasty and 15877-Suction Assistance Lipectomy, Trunk. 

The insurer denied coverage for 19318-Reduction Mammaplasty and 15877-Suction Assistance Lipectomy, Trunk.  The denial is modified. 

This is a female patient with a past medical history of iron deficiency anemia, who has the classic symptoms for macromastia, and medical treatments including analgesics, support bras and topical medications have not improved her symptoms. Her surgeon plans a reduction of at least 900-1000 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.  

A paper was done on this topic 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 Short Form-36 (SF-36), McGill Pain Questionnaire (MPQ), Multidimensional Body-Self Relations Questionnaire (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. 

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." 

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. 

Breast reduction surgery - code 19318 is medically necessary for this patient.  

Liposuction - code 15877 is not medically necessary. The surgeon is planning to perform liposuction of the axillae to remove any lateral breast tissue without making a direct incision. Per the American Society of Plastic Surgeons, liposuction used as an adjunct to breast reduction is a component part of 19318 (the liposuction is being used to reduce breast tissue and therefore this is part of the breast reduction procedure). 

The health plan did not act reasonably in denying code 19318 but did act reasonably in denying code 15877. 

The insurer's denial of coverage for 19318-Reduction Mammaplasty and 15877-Suction Assistance Lipectomy, Trunk is modified. Medical necessity is partially substantiated.