Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic mid thoracic pain
Treatment: Breast reduction surgery
The insurer denied the breast reduction surgery.
The determination is overturned.

This is a female who was complaining of back, neck, and shoulder pain and rashes due to her large breasts. She was treated by the chiropractor with limited improvement. Weight loss has not improved her pain. Her surgeon recommends bilateral breast reduction with the removal of 400-500 grams of tissue from each breast.

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 800 to 1000 grams of tissue. 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. 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-reporting instruments including the 36 item short form survey (SF-36), McGill Pain Questionnaire (MPQ), Multidimensional Body-Self Relations Questionnaire (MBSRQ), and the European Quality of Life Questionnaire (EuroQol)." 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 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 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.