Bilateral Breast Reduction denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for panniculectomy and/or bilateral breast reduction. Based on the medical records provided for review, the requested panniculectomy is not medically necessary for this patient. Specifically, there is no documentation of the presence of intertrigo or infections to support an indication for panniculectomy. In addition, there is no indication that the patient has required treatment with topical therapies to address any skin infection or breakdown. Moreover, the provider did not report any difficulty with the patient’s ability to perform activities of daily living due to the presence of a large pannus. Thus, the requested panniculectomy is not likely to improve the patient’s function.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast reduction (mammoplasty) surgery. According to researchers, reduction mammaplasty is a highly effective procedure for the treatment of symptomatic macromastia. Recent studies have shown that the requirement to specify the expected amount of breast tissue to be resected is an outdated approach for determining if reduction mammaplasty is appropriate. One study concluded that there is no predictable relationship between body surface area and breast weight. Another study found that resection estimate accuracy varies among surgeons and appears to be unaffected by experience. One study investigated whether small-volume resections in reduction mammoplasty produced symptomatic improvement.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for bilateral breast reduction. 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 guidelines indicate that reduction mammaplasty may be performed 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 congenital b…

A 49-year-old female has requested approval for past breast surgery performed on an emergent basis. Findings: The physician reviewer found that the patient underwent breast surgery outside of the United States. She reports that the procedure was performed on an emergent basis. The patient’s clinical history, pre-surgical work-up and operative report have not been provided. At issue in this case is whether a prudent layperson would have sought immediate medical attention on the date at issue.

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 Bilateral Breast Reduction, then check the rights and deadlines that apply to your plan.