Bilateral Reduction Mammoplasty 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

The patient is a 15-year-old male with gynecomastia. According to the record he is not having pain or other physiologic problems related to his breast enlargement. He is said to suffer from low self-esteem, but there is no record of psychological counseling or psychotherapy included for review. The patient’s parent has requested authorization for bilateral reduction mammoplasty. The request was denied by the Health Plan based upon a determination that the procedure is not medically necessary.The record indicates the patient is obese, and obesity is a well-recognized cause of pubertal gynecomastia.

A 53-year-old female enrollee has requested a bilateral reduction mammoplasty for the treatment of her macromastia. Findings: The physician reviewer found that the submitted clinical notes do not contain findings of intertrigo. While the patient’s primary care physician makes reference to chronic shoulder, back and neck pain, treatment notes documenting the chronicity of these complaints have not been provided. The low back complaints are not attributable to breast hypertrophy, though the upper back pain can be causally related to large breasts or other intrinsic cervical or thoracic etiology, the source of which has not been adequately documented in the supplied records. All told, there is inadequate evidence that the proposed mammoplasty is clinically indicated for this patient.

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