Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Back and Neck Pain.
Treatment:  Surgical Services (Breast Reduction).
The health plan denied the requested surgical service.  The health plan's determination is upheld.

This 64.9 kilogram (kg), 5' 4", 145 pound, 34DDD/E bra sized patient complains of back and neck pain, occasional rashes and shoulder bra strap grooving attributed to macromastia. Physical therapy, support bras and chiropractor sessions did not provide relief. Photos show grade 2 ptotic breasts that are not large enough to be considered macromastia and no shoulder bra strap grooving. Preoperatively her surgeon estimated a 375-gram (gm) breast reduction from each breast. An operative report describes 218 gm right and 224 gm left breast reductions with a vertical breast lift. Pathology report on the operative specimens was mammary parenchyma with focal stromal fibrosis, normal skin and corroborating specimen weights. Other photos show grade 1 ptotic breasts that are not large enough to be considered macromastia. There is no detailed breast exam with breast measurements in the reviewed materials. In a letter of appeal her surgeon stated that the complaints have resolved since having the surgery. Her chiropractor also reported symptom relief with improved physical examination following surgery.
At issue is the medical necessity of the requested health service/treatment.

I uphold in whole the health plan's determination of medical necessity.

No, the requested service/treatment of breast reduction surgery is not medically necessary for this patient.
Breast reduction surgery is effective in relieving the symptoms related to large breasts such as back pain, neck pain, skin breakdown, etc. if they are present. The patient did complain of back and neck pain. In this case there are no breast measurements to justify the preoperative presence of macromastia and the submitted photos do not clearly show macromastia or shoulder bra strap grooving from large breasts. Furthermore, the complaints of a skin condition related to macromastia are refuted by the absence of a skin abnormality on the operative specimens and there is no documentation of office visits for, or treatment of such a skin condition.
To further delineate this group of patients a Schnur scale was developed to relate the amount of breast tissue removed to preoperative body mass surface area as a means of differentiating cosmetic from reconstructive medically necessary breast reduction surgery prior to surgery. This also makes intuitive sense because if the surgeon removes a small amount of tissue say less than 75gm it is highly unlikely that would have any effect on back pain much less bra size. Given the absence of any breast cancer, as the amount removed is increased the procedure changes from a cosmetic procedure to a medically necessary reconstructive procedure. The question then arises as to what point this change from cosmetic to medically necessary occur. The answer is it is at a smaller amount for smaller people and a larger amount for larger people. The aforementioned scale accounts for this by relating the amount removed to body surface area (size of the person) rather than just weight or height. To meet these criteria about 50% more tissue would have to have been removed from each breast.
InterQual criteria are a first level screening tool to assist in determining if proposed services are clinically indicated and provided in the appropriate level or whether further evaluation is required. They are based on medical literature and updated yearly. The overall criteria are not met, and the requested health service/treatment of breast reduction surgery was not medically necessary for this patient.