Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic Macromastia

Treatment: breast surgery (breast reduction surgery)

The insurer denied coverage for breast surgery (breast reduction surgery).

The denial is overturned.

This is a female with a history of macromastia. The patient noted a gradual increase in bilateral breast size since puberty. She reported back and shoulder pain, bra strap notching and skin rashes in the inframammary creases. She had used topical agents without improvement. The physician noted that the patient was a good candidate for bilateral breast reduction surgery. 

The patient has large pendulous breasts with shoulder grooving and the classic symptoms for macromastia. Medical treatments have not improved her symptoms. Photos show oversized breasts for the patient's body size (5'1," 108 pounds). Her surgeon plans a reduction of at least 1,000 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. 

Breast reduction is the only treatment that is proven in the medical literature to be curative for symptomatic macromastia; 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 the patient's pain, and surgery provides the only real chance for symptomatic relief. 

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." 

 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."

There was sufficient evidence to support that breast surgery (breast reduction surgery) was considered medically necessary treatment for the patient's condition.

The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient.

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