Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Macromastia.
Treatment:  CPT code 19318-50, Reduction Mammoplasty.

The insurer denied the CPT code 19318-50, Reduction Mammoplasty.  The denial was overturned. 

This is a female patient who consulted a plastic surgeon for symptomatic Macromastia.  The patient reported chronic neck, upper back and shoulder pain unrelieved by nonsteroidal anti-inflammatory medications and professionally fitted bras.  The patient has been diagnosed with shoulder tendonitis, and the weight of her breasts seems to be contributing to this.  There was no other obvious cause for the patient's pain, and she continued to have very heavy, dense breasts despite a prior reduction.  A reduction mammoplasty has been advised.  The plastic surgeon estimates a removal of at least 500 grams per side.

Based on the review of the medical record and literature, breast reduction surgery is medically necessary for this patient.  The patient presents with the classic symptoms for macromastia, and medical treatments have not improved her symptoms.  The patient's 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 literature for this issue 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.  

As per Collins, et al., "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, MPQ, MBSRQ, and 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 study by Scholz et al. also confirms the paucity of benefits from conservative therapy.  

According to Scholtz, et al., "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 study by Strong and Hall-Findlay concluded "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 health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for CPT code 19318-50, Reduction Mammaplasty should be overturned.  The medical necessity is substantiated.