Breast Asymmetry denials in California external review

What the reviewers wrote

Where the denial was 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)…

Findings: The physician reviewer found that a patient has requested reimbursement for a mammaplasty. In this case, the resection of a small volume of tissue from the right breast was below the 22nd percentile of expected resection weight for the enrollee's body surface area and also below the 5th percentile of the lower threshold used in clinical criteria. This would qualify the procedure as not medically required according to weight alone. As such, the requested mammaplasty was not medically necessary for the treatment of the patient’s medical condition.However, although not medically necessary, for some female patients, breast size discrepancy can be a disturbing problem with an adverse impact on their quality of life.The California Reconstructive Surgery Statute requires health insurers to cover reconstructive surgeries, defined as surgeries performed to correct or repair abnormal str…

Where the denial was upheld

A 51-year-old female enrollee has requested bilateral breast implants for the treatment of her breast asymmetry. Findings: The physician reviewer found that although symmetry is the surgical objective of breast reduction surgery, perfect symmetry of nipples, areolae, and breasts cannot be achieved. Furthermore, the two sides of the human body are not the same and can never be made the same. A patient with preoperative asymmetry prior to surgery will most likely have asymmetry after surgery, even though the surgeon strives to decrease the degree of asymmetry at surgery. No surgeon can guarantee or predict final breast size after breast reduction surgery any more than they can after breast augmentation. The error in the preoperative estimate versus final result can be as high as between 1 and 2 cup sizes.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast magnetic resonance imaging. The indications for breast MRI include high and intermediate risk screening, for patients with a new diagnosis of breast cancer, for evaluation of response to chemotherapy prior to surgery, for evaluation of recurrence and metastatic cancer of an unknown primary source, and when mammographic and sonographic findings are inconclusive. In this case, if the asymmetry visualized on diagnostic mammography remained suspicious, then stereotactic biopsy is indicated. The records do not suggest that the breast asymmetry is concerning for implant rupture or that biopsy is not technically feasible.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving breast asymmetry, then check the rights and deadlines that apply to your plan.