Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic macromastia status-post bilateral breast reduction. 
Treatment: Code 19318-50, bilateral breast reduction. 
The insurer denied coverage for: Code 19318-50, bilateral breast reduction. 
The denial is overturned. 

Breast reduction surgery was medically necessary for this patient. The patient had the classic symptoms for macromastia, and the surgeon performed a reduction of 1460 grams of tissue total. Photos show the patient has large pendulous breasts with bra strap grooves. A variety of conservative treatments over three years had not improved the patient's pain. The patient has no co-morbid conditions that could explain her symptoms. Symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for this condition. Non-operative treatments were 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, MPQ, MBSRQ, and EuroQol. 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 study by Scholtz et al confirms the paucity of benefits from conservative therapy.  According to the authors, "Macromastia causes back and neck pain, scaphodynia, intertrigo of the inframammary crease up to dysesthesia. Typical complaints of patients with macromastia are physical burden, psychological irritation and aesthetic deformity, often resulting in social isolation. Despite the demonstrable success of reduction mammaplasty to eliminate not only the symptoms of macromastia but the cause of the ailment, conservative therapy is still favored by insurance companies and bearing of costs for surgical therapy therefore is rejected. Expenses of conservative treatment as well as costs related to appeal and lawsuits against insurance decisions exceed the case-based lump sum of reduction mammaplasty manifold. Conservative treatments do not eliminate the causes of the illness." The patient has large pendulous breasts with shoulder grooving and the classic symptoms for macromastia. 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 were unlikely to improve her pain, and surgery provided the only real chance for symptomatic relief. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for code 19318-50, bilateral breast reduction is substantiated.