Breast Ptosis: when insurers say no, reviewers often say yes

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)…

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reconstruction surgery, lifting of breast implants for treatment of the enrollee’s breast cancer and not reconstructive in nature. Findings: The physician reviewer found that as noted by the American Society of Plastic Surgeons (ASPS), “reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.” Breast reconstruction is done to approximate a normal appearance and this includes complications related to breast reconstruction. Complications can occur following previous successful reconstruction.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral mastopexy surgery with acellular dermal matrix implant, and graft with vascular flow test. The classification of breast ptosis is predicated on the relationship of the nipple to the inframammary fold. In Grade 2 ptosis, the nipple is 1 to 3 cm below the inframammary fold, but is still located above the lowest point of the breast. Mastopexy is a cosmetic procedure that utilizes reconstructive principles from other breast procedures. The goals of mastopexy are to reshape the breast, redistribute volume, and reposition the nipple-areola complex. Breast reduction operations strive for these same aesthetic goals while also reducing the size and weight of the breasts for functional purposes.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for autologous fat grafting. One group of authors note that, “As obesity rates in America continue to climb, plastic surgeons will be asked to resect larger volumes of breast tissue on larger patients. Previous studies have produced conflicting results on the independent association between BMI and resection weights and the development of postoperative complications. Our study, with one of the highest mean BMIs reported for a patient cohort (34.1), demonstrated a statistically significant increase in risk of complications for increasing BMI. We did not, however, find a significant increase in risk of complications based on resection weight.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for breast ptosis was denied, the published record says the denial is worth fighting.