Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal-Back pain. 
Treatment: Surgical Services-Bilateral Breast Reduction surgery. 

The health plan denied Ambulatory Surgery as not medically necessary. 
The health plan's determination is overturned. 

This is a female patient who has macromastia. She complains of back, neck, and shoulder pain. Conservative treatments including physical therapy, chiropractic care, and analgesics have not improved her symptoms. Her surgeon recommends bilateral breast reduction with the removal of 1000 grams of tissue total. 

The health plan's determination of medical necessity is overturned in whole. 

Breast reduction surgery is medically necessary for this patient. The patient 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. This report is based on data from the Breast Reduction Assessment of Value and Outcomes (BRAVO) 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 Survey 36 (SF-36), McGill Pain Questionnaire (MPQ), Multidimensional Body-Self Relations Questionnaire (MBSRQ), and European Quality of Life (EuroQol)." [raised 6] 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."[9] There is no conservative treatment that will relieve this patient's pain. 

The American Society of Plastic Surgeons (ASPS) has published a national standard of care document regarding breast reduction. Based on aggregate high-quality evidence, the 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."[1] 

The patient has large pendulous breasts with shoulder grooving and the classic symptoms for macromastia. Photos show that she has significantly over-sized 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, the requested health service/treatment of Ambulatory Surgery is medically necessary.