Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic macromastia. 
Treatment: Reduction mammoplasty. 

The insurer denied coverage for reduction mammoplasty. 

The denial is overturned. 

Breast reduction surgery was medically necessary for this patient. She had the classic symptoms for macromastia. She had musculoskeletal pain for six years, and medical treatments did not improve her symptoms. Her pain was constant. Her surgeon performed a breast reduction with the removal of over 1400 grams of tissue total. Symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for this condition. Nonoperative treatments are unlikely to improve her pain, and surgery provides the only real chance for symptomatic relief. 

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 2014 study by Strong and Hall-Findlay concluded, "We found that reduction mammoplasty 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 (ASPS) has published a national standard of care document regarding breast reduction. Based on aggregate high-quality evidence, the ASPS 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." 

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. Nonoperative treatments were unlikely to improve her pain, and surgery provided the only real chance for symptomatic relief. 

Based on the review above, reduction mammoplasty was considered medically necessary. 

The health care plan did not act reasonably, with sound clinical judgment or in the best interest of the patient. 

The insurer's denial of coverage for reduction mammoplasty is reversed. Medical necessity is substantiated.