Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Macromastia
Treatment:  Breast Reduction (reduction mammaplasty)
The insurer denied the  Breast Reduction (reduction mammaplasty)
The denial is overturned

The patient is a female that reports a three year history excessive breast skin. She reports dramatic weight loss of 20 pounds and loose/ excessive skin of bilateral breasts since then. She reports excessive breast size. She wears bra size 36DD. She reports that bras/breasts are "tugging on shoulders." She reports modifications of her bra wear, has tried wearing sports bra, and bra straps were tugging even worse. She reports chronic pain of back and shoulders, which she associates with her breast size. She has excessive skin that continues tugging on shoulders. No direct pain at mammary glands. Her pain originates at bilateral trap muscles, feels "very tense." She reports intermittent skin discoloration of her shoulders at bra straps, for which she uses cocoa butter. No inframammary rashes. She has not seen back specialist or chiropractor yet. She would like to have breast reduction. She has one daughter. She does not plan on having future children or breast feeding in the future.  Her pain is unimproved with physical therapy. Photos show a female with long pendulous breasts. Bilateral breast reduction is planned.

Yes. The proposed treatment is medically necessary.
Breast reduction surgery is medically necessary for this patient. She has the classic symptoms for macromastia, and medical treatments have not improved her symptoms. Her surgeon plans a reduction of at least 500 grams of tissue total but based on the photos, the surgeon will likely remove at least twice as much tissue.  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 Breast Reduction Assessment of Value and Outcomes (BRAVO) 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 short form 36 (SF-36), McGill Pain Questionnaire (MPQ), Multidimensional Body Self Relations Questionnaire (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. Conservative treatments do not eliminate the causes of the illness."  
There is no conservative treatment that will relieve this patient's pain. 

A 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 American Academy of Plastic Surgeons (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 shoulder grooving and the classic symptoms for macromastia.

Photos show that she has pendulous 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.

No. The health plan did not act reasonably, with sound medical judgement and in the best interest of the patient.
The patients symptoms have persisted despite physical therapy. Breast reduction is the only treatment that will alleviate her symptoms.