Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast hypertrophy. 
Treatment: Outpatient procedure (19318 x 2). 

The insurer denied coverage for outpatient procedure (19318 x 2). 

The denial is overturned. 

Breast reduction surgery is medically necessary for this patient. She has the classic symptoms for macromastia, and medical treatments, including chiropractor treatments, have not improved her symptoms. Her bra size is DDD. Her surgeon plans a reduction of at least 1050 grams of tissue total.  Symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for this condition. 

"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... Conservative treatments do not eliminate the causes of the illness."  A 2021 study confirmed these findings with the authors concluding: "These results show that reduction mammoplasty is a treatment that not only improves a patient's quality of life but also saves money in the longer term in comparison with expensive and ineffective conservative treatment for macromastia." There is no conservative treatment that will relieve this patient's pain...These data suggest that many patients who are denied coverage for reduction mammoplasty on the basis of low projected reduction specimen weight would derive significant benefit from the procedure."  The American Society of Plastic Surgeons 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 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 are unlikely to improve her pain, and surgery provides the only real chance for symptomatic relief. 

Based on the above, the insurer's denial must be overturned. 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 outpatient procedure (19318 x 2) services is substantiated.