Appeal type: Medical necessity
Decision: Upheld

The patient is a female who presented complaining of significant neck back and shoulder pain due to large pendulous breasts.  The patient complains of difficulty finding supportive bras and difficulty with physical activities due to her large pendulous breasts.  She also complains of frequent rashes and moisture underneath her breasts and bra strap grooving.  The patient has attempted to treat her symptoms using nonsteroidal anti-inflammatory medication, as well as chiropractic treatment, with only limited relief.  The examination documents moderate macromastia with grade 3 mammary ptosis and bra strap grooving but no active ulcerations or rashes.  The patient had consultation with a plastic surgeon, who had recommended a bilateral breast reduction procedure removing approximately 505 grams of tissue from each breast.  The patient underwent a bilateral breast reduction procedure removing 278 grams of tissue from the right breast and 308 grams of tissue from the left breast.  The subject under review is the medical necessity of the bilateral breast reduction.

The health plan's determination is upheld, in whole. 

In the absence of documentation of significant physical symptoms causing functional impairment and in the absence of documentation of failure of medical supervised conservative therapy, the requested service does not meet standard of care for medically necessary breast reduction surgery.  In addition, the amount of tissue removed is significantly small and likely will not provide the patient with significant volume reduction leading to improvement of macromastia symptoms.  Failure to provide this service will not adversely affect the patient's long-term health and welfare.

Based upon a review of the clinical information provided, clinical practice standards and peer-reviewed literature established by the American Society plastic surgeons, the request for approval for the bilateral breast reduction procedure does not meet the medical necessity criteria established by the relevant medical community.

The clinical documentation does not demonstrate that the patient suffers from any significant physical symptoms that are causing functional impairment impairing the patient's ability to perform activities of normal daily living and there is no documentation that the patient has failed at least a three-month trial of a medically supervised conservative therapy including but not limited to, physical therapy, the use of appropriate support bra with weight distributing straps, anti-inflammatory agents, and appropriate local hygiene and topical pharmacologic treatments for intertrigo. In the absence of the appropriate documentation, the requested bilateral reduction mammoplasty procedure may be considered a cosmetic procedure that is not medically necessary for this patient. The clinical documentation provided does not satisfy the typical standard criteria for coverage of the bilateral breast reduction procedure for functional indications since there is no documentation that the patient suffers from any significant functional impairment related to the presence of the size and volume of the breast tissue. The clinical documentation provided only makes reference to failure of conservative therapy and does not document using progress notes or prescriptions with the specific treatments employed and duration of treatment. There are no extenuating circumstances, such that this procedure is medically necessary for functional indications because the patient does not have any significant functional impairment or physical symptoms related to the size and volume of the breast tissue.