Macromastia denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient is a female who has been diagnosed with bilateral macromastia. The provider noted the patient had undergone previous breast surgeries, including breast augmentation and mastopexy. The patient has developed breast enlargement and ptosis with time, and a breast reduction was requested due to her breasts being large, heavy, and pendulous. Physical examination findings included bilateral pseudoptosis in dense fibroglandular breasts. The patient reported the size and weight of her breasts were pulling on her back, neck, and shoulders. Photographs of the patient show breast asymmetry, with the right breast larger than the left. Marked pseudoptosis is present, with almost all the breast volume below the level of the nipple. Shoulder grooving is present. The patient underwent bilateral reduction mammoplasty.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: This patient has a history of macromastia. The patient was evaluated for a breast reduction on 6/24/2022. The patient reported chronic neck pain, back pain, and shoulder pain. The patient is five feet six inches tall and weighs approximately 231 pounds with a body mass index (BMI) of 37.41. The patient wears a size 42G bra. The patient right nipple areolar complex measures 40 cm from the sternal notch and the left measures 30 cm. The patient has attempted to lose weight but even with weight loss the breasts remain large. The size of The patient's breast makes it difficult to exercise. The Health Plan indicates that the requested treatment is not medically necessary for the treatment of the patient’s medical condition.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast reduction and/or trunk lipectomy. With regard to the requested breast reduction, researchers stated that reduction mammaplasty 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 signs such as chronic breast pain due to the weight of the breasts, shoulder grooving, intertrigo unresponsive to medical management, headache, or congenital breast deformity. The records document that this patient complains of back, shoulder, and neck pain. However, there is a lack of documentation of shoulder grooving by physical examination or by photographs.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for bilateral breast reduction surgery. The American Society of Plastic Surgeons (ASPS) guidelines state that reduction mammaplasty should be performed based on documentation of the severity of the symptoms of macromastia and its impact on health-related quality of life. The ASPS guidelines indicate that reduction mammaplasty may be indicated if at least two of the following quality-of-life signs are present: chronic breast pain due to breast weight, intertrigo unresponsive to medical management, upper back, neck, and shoulder pain, backache, 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…

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 macromastia, then check the rights and deadlines that apply to your plan.