Bilateral Mastectomy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral mastectomy and liposuction procedure (CPT 19300 and 15877). Arya and colleagues state that, “True gynecomastia refers to enlarged glandular tissue rather than deposition of fat tissue. Enlargement of breast due to deposition of fat in the breast area is known as pseudogynecomastia.” The authors noted that, “The aims of surgery are: (a) To eliminate painful breast tissue. (b) To restore the patient’s chest to acceptable cosmetic shape. The most commonly used technique is subcutaneous mastectomy that involves direct resection of the glandular tissue using a peri-areolar or trans-areolar approach, with or without liposuction.” Per the American Society of Plastic Surgeons (ASPS), the requested bilateral mastectomy and liposuction procedure are not medically necessary.

Nature of Statutory Criteria/Case Summary: The patient presents with a history of gender dysphoria, anxiety and depression. The records document that the patient is status post orchiectomy and has received treatment with hormone therapy. Per the documentation, an abnormal chest size and shape was noted for the patient’s body-mass index. Per the submitted documentation, the patient is frequently mistaken for a female in public. The documentation noted that the patient has been wearing a chest binder 24 hours a day, seven days a week (including during sleep) for several years. This appears to have resulted in permanent bruising and rib cage disfigurement. The patient has been unable to engage in healthy levels of physical activity and exercise, especially in warmer weather, due to the chest size and shape.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral mastectomy. According to the American Society of Plastic Surgeons (ASPS), “gynecomastia is defined as the presence of an abnormal proliferation of breast tissue in males.” However, the ASPS noted that, “in pseudogynecomastia, the breast enlargement is secondary to fat accumulation; and both glandular and fat tissue are present in mixed gynecomastia. Gynecomastia is different from pseudogynecomastia, which is an increase in subareolar fat often related to obesity.

Nature of Statutory Criteria/Case Summary: The patient is requesting authorization and coverage for bilateral mastectomy gynecomastia surgery. The Health Plan has denied the request as not medically necessary for treatment of the patient’s medical condition.Gynecomastia is defined as the presence of an abnormal proliferation of breast tissue in males. It is a common breast lesion, accounting for more than 655 of male breast disorders. Gynecomastia has a broad range of causes that are classified as either physiological or pathological, although in many cases, no specific cause can be found. In true gynecomastia, the breast enlargement is due to glandular breast tissue; in pseudogynecomastia, the breast enlargement is secondary to fat accumulation; and both glandular and fat tissue are present in mixed gynecomastia.

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