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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for reduction mammaplasty. Findings:  The physician reviewer found that Women with increased breast size experience symptoms such as pain in the neck, shoulders and lumbar spine, headache, intertrigo in the inframammary fold, difficulty in performing daily activities, paresthesia in the hands (due to weight on the anterior chest wall and compression of the brachial plexus), difficulty in exercising, low self-esteem, and body dissatisfaction. Per the American Society of Plastic Surgeons (ASPS), reduction mammaplasty should be based on documentation of the severity of the symptoms of macromastia and impact on health-related quality of life. The ASPS states that patients with symptoms of macromastia and at least two confirmed quality of life signs are candidates for reduction mammaplasty. This patient presents with complaints of back and shoulder pain with shoulder grooving. However, these findings are not confirmed on physical examination or in the photographs. The records do not include documentation of chronic breast pain due to weight of the breasts, intertrigo unresponsive to medical management, thoracic kyphosis, headache, or congenital breast deformity. Moreover, no proposed weight of resection was provided for review. In the absence of at least two confirmed quality of life signs, the requested reduction mammaplasty does not meet ASPS criteria. Given these findings, the requested reduction mammaplasty is not medically necessary for 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: (1) to improve function; (2) to create a normal appearance, to the extent possible. This patient complains of extreme pain, numbness, and difficulty breathing from the weight of her breasts. However, there is a lack of physical findings documented in the records reviewed to support her complaints. In addition, the provider did not report an estimate of the proposed weight of resection. There is no functional deficit documented related to the patients breasts. Moreover, the requested surgery would not provide a more than minimal improvement in the patients appearance. For these reasons, the requested reduction mammaplasty is not reconstructive in nature for this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.