Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Macromastia. 
Treatment: Breast Reduction Surgery (19318). 

The insurer denied: Breast Reduction Surgery (19318). 
The denial is overturned. 

The patient is an adult female. She has complaints related to the size of her breasts. The patient complains of neck, back and shoulder pain. Additional complaints include difficulty finding supportive bras and difficulty with certain physical 
activities. The patient has tried conservative therapy consisting of physical therapy and chiropractic therapy without significant improvement in her symptoms. The patient on physical exam is 5' 3" tall and weighs 180 pounds. Her weight is stable. The patient wears a 38 G bra size. Examination reveals severe macromastia. Her surgeon recommends bilateral breast reduction. 

The requested Breast Reduction Surgery (19318) is medically necessary. 

Breast reduction surgery is medically necessary for this patient. Her surgeon plans a reduction of at least 700 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 [Short Form-36], MPQ [McGill Pain Questionnaire], MBSRQ [Multidimensional Body Self Relations Questionnaire], and EuroQol [European Quality of Life questionnaire]. 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 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 has published a national standard of care document regarding breast reduction. Based on aggregate high-quality evidence, the ASPS (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." 

There is no conservative treatment that will relieve this patient's pain. The 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. Non-operative treatments are unlikely to improve her pain, and surgery provides the only real chance for symptomatic relief.