Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Large breasts causing pain
Treatment: Breast reduction surgery (19318x2)
The insurer denied: Breast reduction surgery (19318x2).
The denial is overturned.

This patient is an adult female who states that she has had pain in her back and neck for at least several months and attributes the symptoms to the large size of her breasts. She states that she has difficulty exercising and has to wear multiple bras at the same time. She is currently having physical therapy for her back and neck pain. She wears size 34D bra and wishes to be a small C cup size. There is no family history of breast cancer.

On physical examination, the patient is 63 inches tall and weighs 156 pounds. Her body mass index (BMI) is 27.6 and her body surface area is 1.78 meters squared (m2). Examination of her breasts reveals large pendulous breasts with grade 2 ptosis. Her symmetry is good. There are no masses. However, on the left breast medial upper aspect there is a 5-millimeter atypical nevus. The distance from sternal notch to the nipple is 26 centimeters left side, 26.5 centimeters right side. Internipple distance is 24.5 centimeters. Inframammary fold to nipple distance is 8 centimeters bilaterally. Breast reduction is planned with removal of 800 grams of tissue total.

The requested health service 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 800 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 (36-Item Short Form Survey Instrument), MPQ (Multidimensional Personality Questionnaire), MBSRQ (Multidimensional Body-Self Relations Questionnaire), and EuroQol (health-related quality of life measurement). 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."

The American Society of Plastic Surgeons has published a national standard of care document regarding breast reduction. Based on aggregate high-quality evidence, the 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."

This 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.