Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Bilateral macromastia with back, neck and shoulder pain. 
Treatment:  Reduction mammoplasty (procedure code 19318). 

The insurer denied coverage for the reduction mammoplasty (procedure code 19318).  The denial is overturned. 

This is a female patient with a history of bilateral macromastia, gastroesophageal reflux disease (GERD), and prediabetes.  The patient presented to the plastic surgeon's office with complaints of back pain, shoulder pain, neck pain, and shoulder grooving from the weight of the breasts.  The patient had sessions with a physical therapist for six months with no improvement in pain.  The patient's pain and symptoms affect her daily activities.  The physician believes that she is a good candidate for a bilateral breast reduction in order to alleviate pain in the patient's back, shoulders, and neck. 

The patient has the classic symptoms for macromastia, and medical treatments including physical therapy sessions have not improved her symptoms.  The patient's treating physician recommends reduction mammoplasty to treat this patient's symptomatic macromastia refractory to conservative treatment.  As per literature review, symptomatic macromastia is a mechanical problem, and conservative treatments have been shown to be ineffective for this condition.  Thus, non-operative treatments are unlikely to improve this patient's pain, and surgery provides the only real chance for symptomatic relief. 

As per Collins and Kerrigan, "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....  Pain is a significant symptom in this disease, and both pain and overall health status are markedly improved by breast reduction.  In this population, conservative measures such as weight loss, physical therapy, special brassieres, and medications did not provide effective permanent relief of 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. 

As per Strong and Hall-Findlay, "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", and recommends "freedom for the surgeon to make a decision on potential benefits of surgery based around the needs of each individual patient." 

In this case, the patient has large pendulous breasts with rashes and the classic symptoms for macromastia.  Breast reduction is the only treatment that is proven in the medical literature to be curative for symptomatic macromastia, and multiple 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 this patient's pain, and surgery provides the only real chance for symptomatic relief.  Thus, the reduction mammoplasty procedure is considered medically necessary for this patient. 

The health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the reduction mammoplasty (procedure code 19318) should be overturned.  The medical necessity is substantiated.