Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgery Services. 
The insurer has denied breast reduction. 
The denial is overturned, in whole.

The patient is a female with bilateral macromastia. The patient has a several year history of back, neck, and shoulder pain unresponsive to non-steroidal anti-inflammatory drugs (NSAIDs) due to the large size of her breasts. In addition, the patient suffers from inframammary fold intertrigo with severe itching, redness, and irritation refractory to topical creams and powders. Neurologic, orthopedic, or rheumatologic causes have been ruled out. The patient also suffers from painful shoulder grooving from her bra straps caused by the weight of her large breasts. Due to failure of conservative treatment measures, she is indicated for surgical reduction. A bilateral breast reduction is planned with the expectation of at least 500 grams per breast to be excised. The patient is currently: bra size 32I, weight 140 lbs. height 5'2 inches. The subject under review is the medical necessity for the requested breast reduction.

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 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. 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, 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. 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 patient has large pendulous breasts with shoulder grooving and the classic symptoms for macromastia. Photos show that she has 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.