Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for mastopexy (CPT 19371) and breast reduction (CPT 19318). Findings:  The physician reviewer found that Cabral and colleagues state 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, difficulty in exercising, low self-esteem, and body dissatisfaction. The American Society of Plastic Surgeons (ASPS) states that reduction mammaplasty authorization should be based on documentation of the severity of the symptoms of macromastia and impact on health-related quality of life with at least two of the following signs: (1) chronic breast pain due to weight of the breasts; (2) intertrigo unresponsive to medical management; (3) upper back, neck, and shoulder pain; (4) backache, unspecified; (5) thoracic kyphosis, acquired; (6) shoulder grooving from bra straps; (7) upper extremity paresthesia due to brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area; (8) headache; (9) congenital breast deformity. In this case, the patients photographs confirm marked breast asymmetry in size before implant removal, with the right breast significantly larger than the left. Both of the patients breasts show ptosis, the right breast more than the left. The patient complains of neck, back and shoulder pain due to asymmetric breasts and of constant rash and skin irritation under her breast. There is no documentation or report of shoulder grooving. She complains of intertrigo, but there is no documentation that it is unresponsive to medical management. The records do not document chronic breast pain due to weight of the breasts, thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. Since there are less than two documented quality of life signs, a breast reduction would not meet ASPS criteria. Therefore, the requested breast reduction is not medically necessary for treatment of the patients medical condition. The patient also requests authorization for mastopexy following breast implant removal. No functional complaints were received regarding breast ptosis other than potentially intertrigo, which was not demonstrated to be unresponsive to medical management. Therefore, the requested mastopexy is not medically necessary for treatment of the patients medical condition.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. Breast ptosis is not an abnormal structure of the body. It is a normal structural change that is associated with aging. Therefore, the mastopexy for the correction of breast ptosis is not considered reconstructive. Significant breast size asymmetry is an abnormal structure of the body due to developmental abnormalities. A functional abnormality due to asymmetric breast size has not been documented. However, a breast reduction would create a normal appearance, to the extent possible, and would be considered reconstructive. Therefore, the requested breast reduction (CPT 19318) is reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. However, the breast reduction is reconstructive in nature. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism 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.