Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic macromastia. 

Treatment: Ambulatory Surgery - Outpatient Procedure (19318x2). 

The insurer denied coverage for Ambulatory Surgery - Outpatient Procedure (19318x2). 

The denial is overturned. 

This is a female patient with a history of right breast mass and minimal scoliosis. The patient presented to an Internal Medicine Physician and Aesthetic Specialist due to enlarging breasts, size F. The notes state that patient is unable to find the right size bra and has persistent upper back pain. The tried Physical Therapy (PT). Surgical reduction was requested, which the insurer/health plan denied.  

The health plan did not act reasonably with sound judgment in the best interest of the patient. Breast reduction surgery is medically necessary for this patient. She has the classic symptoms for macromastia, and medical treatments including physical therapy have not improved her symptoms.  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.  

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 American Society of Plastic Surgeons m 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 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 insurer's denial of coverage for Ambulatory Surgery - Outpatient Procedure (19318x2) is overturned. Medical Necessity is substantiated.