Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back, neck and shoulder pain. 
Treatment: Breast Surgery (breast reduction, reduction mammaplasty-procedure code 19318). 

The insurer denied the Breast Surgery (breast reduction, reduction mammaplasty-procedure code 19318). 
The denial is overturned. 

The patient is a female. She complains of back, neck and shoulder pain due to her large breasts. She has rashes and difficulty exercising. Her bra size is DD. NSAIDs (non-steroidal anti-inflammatory drugs) have not improved her symptoms. Her surgeon recommends bilateral breast reduction. Photos show a female with large breasts and shoulder grooving. 

Yes, the requested breast reduction surgery 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. She has large breasts with shoulder grooving, and no co-morbid conditions that can explain her symptoms.  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 (1).  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." 

A 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." 

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." 

There is no conservative treatment that will relieve this patient's pain. 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. Non-operative treatments are unlikely to improve her pain, and surgery provides the only real chance for symptomatic relief. 

Therefore, given the above, the requested breast reduction surgery is medically necessary. 

Breast reduction is the only curative treatment for her condition. There is no other treatment that will permanently correct her condition.