Female Breast Dis 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 reduction mammoplasty and panniculectomy. This patient presents with evidence of significant symptomatic bilateral macromastia that has failed reasonable conservative management. She has evidence of chronic neck, back and shoulder pain, as well as shoulder grooving and breast pain, which limit her daily activity. She has also a history of chronic rashes underneath her breasts that has failed typical conservative management with antifungal medication and creams. The medical documentation, including review of the photographs, supports that her macromastia is likely contributing significantly to her functional complaint of pain and chronic rashes. Moreover, she has failed typical conservative management including weight loss and typical dermatologic treatment.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reconstruction (removal and replacement of breast implants). From the American Society of Plastic Surgeons (ASPS), breast deformities “result from congenital anomalies, trauma, disease, or maldevelopment. Because breast deformities often result in abnormally asymmetrical breasts, surgery of the contralateral breast, as well as the affected breast, may be required to achieve symmetry.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right breast implant repair. Examination details, and review of the provided photographs, do not support that there is an obvious significant deformity of the patient’s right breast. The right breast saline implant is noted to be intact and without apparent deforming capsular contracture. Although the patient complains of pain, there is not sufficient documentation from the plastic surgeons that this is related to a significant capsular contracture or to justify surgical repair of the right breast implant. Attempts to improve the patient’s breast implant asymmetry at this time should be considered relatively aesthetic in nature. The plastic surgeon who evaluated the patient two weeks after mammography was performed noted that any asymmetry was related to the patient’s breast augmentation.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reduction mammoplasty for treatment of her back, neck and shoulder pain. Findings: The physician reviewer found that the patient with evidence of possible symptomatic macromastia. She has chronic neck and back pain that affects her posture negatively and activities of daily living. She has undergone conservative management of her pain with physical therapy, stretching and medical management. She has suggestion of possible symptomatic macromastia. However, the planned amount of resection was not provided for this patient. The American Society of Plastic Surgeon has guidelines for the requested procedure.

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 female breast dis, then check the rights and deadlines that apply to your plan.