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

Nature of Statutory Criteria/Case Summary: The patient is a  female who has been diagnosed with bilateral macromastia. The provider noted the patient had undergone previous breast surgeries, including breast augmentation and mastopexy. The patient has developed breast enlargement and ptosis with time, and a breast reduction was requested due to her breasts being large, heavy, and pendulous.   Physical examination findings included bilateral pseudoptosis in dense fibroglandular breasts. The patient reported the size and weight of her breasts were pulling on her back, neck, and shoulders. Photographs of the patient show breast asymmetry, with the right breast larger than the left. Marked pseudoptosis is present, with almost all the breast volume below the level of the nipple. Shoulder grooving is present. The patient underwent bilateral reduction mammoplasty.  The patient has requested reimbursement for bilateral reduction mammoplasty. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient and were not reconstructive in nature. This denial is the subject of this appeal and determination.  At issue in this case is whether bilateral reduction mammoplasty was medically necessary for the treatment of this patient. In addition, does the patients condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital defects; developmental abnormalities; trauma; infection; tumors or disease? If so, is the requested surgery performed to do either of the following: improve function; create a normal appearance to the extent possible; or restore asymmetry? If so, does the surgery provide more than a minimal improvement in the appearance of the patient? Reports noted, Symptomatic breast hypertrophy is defined as a syndrome of persistent neck and shoulder pain, painful shoulder grooving from brassiere straps, chronic intertriginous rash of the inframammary fold, and frequent episodes of headache, backache, and neuropathies caused by heavy breasts caused by an increase in the volume and weight of breast tissue beyond normal proportions. Studies noted, The scientific evidence from high quality, randomized controlled trials indicates that reduction mammaplasty is effective at reducing symptomatic breast hypertrophy-related symptoms and improving quality of life. Studies noted, Insurance coverage criteria for symptomatic breast hypertrophy should be based upon documentation of at least two symptoms. In this case, the patient reported back, shoulder and neck pain. Photographs of the patient show shoulder grooving. Because there are at least two quality of life signs, the requested service is medically indicated according to criteria. Therefore, bilateral reduction mammoplasty was medically necessary for the treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: to improve function or to create a normal appearance, to the extent possible. In this case, the patients condition constituted an abnormal structure of the body. Breast hypertrophy is an abnormal structure of the body caused by a developmental abnormality. The services at issue were performed to improve the patients function by way of pain relief. The medical evidence supports the service at issue in this clinical setting. Therefore, bilateral reduction mammoplasty was reconstructive in nature.Final Result: The reviewer determined that the service at issue was 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.