Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Bilateral mammary hypertrophy.
Treatment:  Breast Reduction Surgery (19318 x 2).

The insurer denied: Breast Reduction Surgery (19318 x 2).  The denial is overturned.

The patient is an adult female. She complains of bilateral mammary hypertrophy. She has excessive breast tissue. The weight of the breasts has caused neck pain, upper back pain, and intertrigo for more than two years. She wears a 40DD bra. She has thoracic back pain with neck pain, due to the weight of her breasts. She has been suffering with this pain for years and it interferes with her daily life. She also experiences tension headaches due to the excess weight on her neck. She does take anti-inflammatory pain medication, but this has not helped with the back pain. She does use powders and prescription cream as well for the rash and moisture. The plan is to remove 800 grams per side.

The requested Breast Reduction Surgery is medically necessary.

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 1600 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 [Short Form-36], MPQ [McGill Pain Questionnaire], MBSRQ [Multidimensional Body Self Relations Questionnaire], and EuroQol [European Quality of Life questionnaire]. 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 2021 study confirmed these findings with the authors concluding: "These results show that reduction mammoplasty is a treatment that not only improves a patient's quality of life but also saves money in the longer term in comparison with expensive and ineffective conservative treatment for macromastia." There is no conservative treatment that will relieve this patient's pain. The American Society of Plastic Surgeons has published a national standard of care document regarding breast reduction. Based on aggregate high-quality evidence, the ASPS (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." The patient has large pendulous breasts with shoulder grooving and the classic symptoms for macromastia. Photos show that she has significantly 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. Therefore, the requested health service is medically necessary.