Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Macromastia

Treatment: Removal of tissue from the breast, reduction mammaplasty 

The insurer denied coverage for removal of tissue from the breast, reduction mammaplasty

The denial is overturned

This patient presented to the Plastic Surgeon's office for an evaluation of back, neck, and shoulder pain. She reported having difficulty exercising due to her large breasts. The patient tried numerous over the counter pain medications, heating pads, a transcutaneous electrical nerve stimulation (TENS) machine, and massage without relief. The patient is a good candidate for bilateral breast reduction surgery. At least 500 grams need to be removed from each breast. 

The patient has the classic symptoms for macromastia, and medical treatments have not improved her symptoms. Her surgeon plans a reduction of at least 1000 grams of tissue total.  Three physicians have recommended the procedure to treat her chronic musculoskeletal pain. 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 [short form]-36, MPQ [McGill Pain Questionnaire], MBSRQ [Multidimensional Body-Self Relations Questionnaire], and EuroQol [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."

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 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 deep shoulder grooving and the classic symptoms for macromastia. Photos show that she has oversized breasts with deep shoulder grooves. 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 health plan did not act reasonably and in the best interest of the patient. The breast reduction is medically necessary.

Based on the above, the medical necessity for the removal of tissue from the breast, reduction mammaplasty is substantiated. The insurer's denial is overturned.