Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 17-year-old female who reports back pain that worsens with exercise. The patients parent has requested authorization and coverage for breast reduction surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient and are not reconstructive in nature. This denial is the subject of this appeal and determination. The physician reviewer found that Cabral and colleagues stated, Women with increased breast size experience symptoms such as pain in the neck, shoulders and lumbar spine, headache, intertrigo in the inframammary fold, difficulty in performing daily activities, paresthesia in the hands (due to weight on the anterior chest wall and compression of the brachial plexus), difficulty in exercising, low self-esteem, and body dissatisfaction. The American Society of Plastic Surgeons 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 complains of back pain. Shoulder grooving is not reported on physical examination or documented on photographs received for review. 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. Since there are less than two documented quality of life signs, the requested service would be considered not medically necessary according to American Society of Plastic Surgeons criteria. The American Society of Plastic Surgeons has indicated that the decision to perform reduction mammaplasty should be based on patient symptoms and a surgeons 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 American Society of Plastic Surgeon  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. The article does not establish a defined lower weight for breast resection; it establishes a range. According to the article, 404 grams would be the lower 22nd percentile of weight resection for a BSA of 1.75, with 258 grams being the lower 5th percentile of weight of resection with a BSA of 1.75. According to the article, if the patients data plot is above the 22nd percentile, the motivation is purely medical. If the data plot below the 5th percentile, the motivation is purely cosmetic. If the data plot is between the two lines, the motivation is mixed and must be looked at individually. In this case, the proposed resection of 300 grams per breast is below the 22nd percentile of 404 grams per breast at a BSA of 1.75 and above the 5th percentile of 258 grams per breast at a BSA of 1.75. This would qualify the motivation as mixed according to weight. Combining this mixed determination of medical necessity based on weight with the lack of determination of medical necessity based on American Society of Plastic Surgeons criteria, the requested service of bilateral reduction mammaplasty is not medically necessary for the treatment of 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 has large breasts which are ptotic. The appearance of the breasts is within the wide range of normal for female breasts. Breasts within the wide range of normal are not abnormal structures of the body. The California Reconstructive Surgery Statute does not apply to this patient.