Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral macromastia
Treatment: Breast reduction surgery
The insurer denied coverage for breast reduction surgery
The denial is overturned

The health plan did not act reasonably. Breast reduction surgery is medically necessary for this patient. She has the classic symptoms for macromastia, and multiple 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 (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 (short form survey)-36, MPQ (multidimensional personality questionnaire), MBSRQ (multidimensional body self-relations questionnaire), and EuroQol (European quality of life). 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." There is no conservative treatment that will relieve this patient's pain. A 2014 study by Strong and Hall-Findlay concluded, "We found that reduction mammaplasty 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 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. 

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

The insurer's denial of coverage for breast reduction surgery is overturned. Medical Necessity is substantiated.