Appeal type: Medical necessity
Decision: Upheld

Diagnosis: macromastia
Treatment: reduction mammaplasty
The insurer denied a reduction mammaplasty. The health plan's determination is upheld. 

The patient is a female with 36DDD bra size. She complains of back pain, shoulder bra strap grooving and intertrigo attributed to macromastia. Her pain interferes with sleep and carrying groceries. In previous years, she was seen in the emergency room for back pain. No rashes were noted at that time. Non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants prescribed at that time and subsequently have not provided relief. Support bras and topical ointments also did not provide relief. A mammogram was reportedly negative. A medication list includes a muscle relaxant. At the examination, there was no rash. She began seeing a dermatologist who prescribed creams for intertrigo, but they have not been effective. A recent examination states "skin no rash". A recent medication list includes hydroquinone cream and steroid cream for under the breasts, face and arms and a muscle relaxant. At the recent examination, the breasts were grade 2 ptotic with shoulder bra strap grooving, sternal notch to nipple distance 26 centimeter (cm) on the right and 25cm on the left and nipple to inframammary fold distance 15cm on the right and 14cm on the left. Photos show grade 2 ptotic breasts, right shoulder bra strap grooving. There are no views of the under surface of the breasts.
Her surgeon is proposing breast reduction surgery with the removal of 500 gm (grams) or more from each breast to treat her complaints. 

The reduction mammaplasty is not medically necessary for this patient at this time.
InterQual criteria are a first level screening tool to assist in determining if proposed services are clinically indicated and provided in the appropriate level or whether further evaluation is required. They are based on medical literature and updated yearly.
 
The 2021 InterQual criteria for coverage of breast reduction surgery are:
1.	Age 18 or older [MET]
2.	Bilateral macromastia [MET by documented breast measurements and submitted photos]
3.	2 or more of:
a.	chronic back, neck or shoulder pain and other etiologies excluded [NOT MET because other etiologies have not been excluded]
b.	breast pain from excessive breast tissue and other etiologies excluded [NOT MET]
c.	paresthesias of hand or arms and other etiologies excluded [NOT MET]
d.	permanent shoulder grooving from bra straps [MET]
e.	persistent intertrigo at the inframammary folds [MET] AND
4.	Excess breast tissue to be removed per breast proportional to body surface area one of the following
a.	199gm to 238gm and body surface area (BSA) 1.35 to 1.45
b.	239gm to 284gm and BSA 1.46 to 1.55
c.	285gm to 349gm and BSA 1.56 to 1.69
d.	350gm or more [MET]
5.	One of the following:
a.	40 or older and magnetic resonance imaging (MRI), Mammogram, ultrasound or biopsy negative for tumor or malignant changes [NOT MET]
b.	39 younger and symptomatic or high risk of breast cancer and MRI, Mammogram, ultrasound or biopsy negative for tumor or malignant changes
c.	patient 39 and asymptomatic without high risk of breast
In this patient's case, the coverage criteria are not met. In order to meet criteria for the proposed reduction mammaplasty, a negative mammogram is required for the surgery to be medically necessary. The actual 2019 mammogram result is not documented, and she has not had a mammogram within a year of the proposed surgery. Therefore, the surgery is not indicated at this time.