Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast reduction surgery. 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. The American Society of Plastic Surgeons (ASPS) guidelines on reduction mammaplasty note that documentation of the severity of the symptoms of macromastia and impact on health-related quality of life should include at least two of the following signs: chronic breast pain due to weight of the breasts, intertrigo unresponsive to medical management, upper back, neck, and shoulder pain, backache, acquired thoracic kyphosis, shoulder grooving from bra straps, upper extremity paresthesia due to brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area, headache, and congenital breast deformity. The ASPS further notes that the decision to perform reduction mammaplasty should be based on patient symptoms and a surgeons assessment of the likelihood of benefit as opposed to the amount, or weight, of breast tissue to be removed. In this case, the patient reports back, shoulder and neck pain. A physical examination and submitted photographs documented shoulder grooving. The patient reports persistent intertrigo, although without records documenting a lack of response to medical management. In this case, the patient meets ASPS medical necessity criteria for reduction mammaplasty due to documentation of the presence of at least two quality-of-life signs. A more common and accepted practice to determine medical necessity is using a measurement of body surface area and weight removed. In this case, the proposed resection of over 600 grams per breast is above the 22nd percentile of 565 grams per breast at a body surface area of 1.94 m2. Given that this patient meets the ASPS criteria and as the procedure is medically indicated according to weight, the requested service is medical indicated. Therefore, bilateral breast reduction surgery is medically necessary for the 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. In this case, extremely large breasts are abnormal structures of the body caused by developmental abnormalities. The purpose of breast reduction surgery is to improve function by relief of pain. Thus, bilateral breast reduction surgery is reconstructive in nature for this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned.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.