Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage reduction mammoplasty and panniculectomy. This patient presents with evidence of significant symptomatic bilateral macromastia that has failed reasonable conservative management. She has evidence of chronic neck, back and shoulder pain, as well as shoulder grooving and breast pain, which limit her daily activity. She has also a history of chronic rashes underneath her breasts that has failed typical conservative management with antifungal medication and creams. The medical documentation, including review of the photographs, supports that her macromastia is likely contributing significantly to her functional complaint of pain and chronic rashes. Moreover, she has failed typical conservative management including weight loss and typical dermatologic treatment. According to the American Society of Plastic Surgeons (ASPS), reduction mammaplasty may be indicated for patients with symptomatic breast hypertrophy. Eligible candidates should have documentation of at least two symptoms including chronic breast pain due to weight of breasts, intertrigo unresponsive to medical management, and upper back and shoulder pain, or back pain, shoulder grooving from bra straps, or headaches. The patient satisfies these criteria with well-documented, chronic back, shoulder, breast and neck pain, as well as shoulder grooving. Moreover, she has chronic intertrigo despite treatment with medical management which has significantly impacted her daily activities. Based on this, the requested breast reduction in this patient is consistent with standard of care and is supported as medically necessary.In addition, the patient has evidence of a symptomatic abdominal pannus that is documented to be significantly overlapping on examination. She is noted to have functional impairment with chronic intertrigo despite conservative treatment with medications. The American Society of Plastic Surgeons (ASPS) state that when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. Furthermore, noted that the abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. The patient has evidence of 3-4 inches of overlap which is significant enough to cause her well-documented chronic intertrigo. Given these findings, the requested panniculectomy is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.