Appeal type: Surgery
Decision: Favorable

We decided that the Plan does not have to pre-approve breast reduction surgery.
You asked the Plan to pre-approve breast reduction surgery. You say that this surgery is medically necessary.
The Plan denied your request. The Plan says Medicare coverage criteria are not met. MAXIMUS overturned
the Plans denial. The Plan requested a reopen stating MAXIMUS did not apply the correct coverage criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that cosmetic
procedures and related services are not covered. Only services that are reasonable and necessary for the
diagnosis or treatment of illness or injury are coverable. At issue is coverage for breast reduction surgery.
The MAXIMUS Physician Reviewer determined that the requested surgery was medically reasonable and
necessary for this enrollee and is consistent with the standard of care. "There was no other viable alternative to
help with the enrollee's severe functional impairment." The health plan has requested a re-opening, citing an
error on the face of the evidence. The Plan has stated that it disagrees with our consultant's determination. The
plan argues that there is medical evidence of a substantially higher risk of breast reduction surgery in patients
with a BMI greater than 30. The plan states that the surgical benefit does not outweigh the surgical risk due to
the enrollee's elevated BMI and her comorbid conditions, including hypertension, hyperlipidemia, sleep apnea,
and intermittent asthma.
Our Medical Director reviewed the case file, the reopening request, and the medical review. The medical
records show you have a BMI of 44. A plastic surgery consultation was obtained on December 13, 2016 for
evaluation of breast reduction surgery. At that time, weight loss was advised followed by re-evaluation. The
plastic surgery note dated January 9, 2022 documents the following from the treating physician: "I had a
lengthy discussion with the patient with regards to risks associated with performing a breast reduction at her
current weight. The risks for wound breakdown wound dehiscence infections is significant in patients with a
BMI is greater than 35. I have experience these on a firsthand basis. The patients have open wounds which are
difficult to deal with and are extremely painful per patient accounts. The standard of care which is echoed in
our plastic surgery literature and other surgeons is to perform these procedures safely with BMI is closer to 30.
I addressed all the patient's concerns or questions and informed her that given her current weight it would be
unsafe for me to offer her any form of elective surgery including bilateral breast reduction." It is documented
elsewhere in the medical record that the enrollee refuses to lose weight and refuses to discuss weight loss
options. Given the documentation by the plastic surgeon, the documentation does not support that breast
reduction surgery is medically reasonable and necessary for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of breast reduction surgery have not been met. Therefore, we decided that the Plan
does not have to pre-approve breast reduction surgery.