Breast Reduction denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that the patient requested authorization and coverage for panniculectomy, abdominoplasty, mastopexy, and breast reduction and augmentation.A review of medical literature reveals that panniculectomy is crucial not only for improving physical appearance but also for addressing functional issues such as skin irritation and rashes caused by excess skin. This procedure addresses the excess skin and pannus causing skin irritation, rashes, and functional issues such as difficulty with hygiene and the potential risk of infection. Removing the excess skin is beneficial for physical comfort and hygiene but also serves a reconstructive purpose by restoring a more functional and normal appearance to the abdominal area. However, abdominoplasty, which is the tightening of the abdominal muscles, is not medically appropriate as it is cosmetic in nature.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mastopexy (CPT 19371) and breast reduction (CPT 19318). Findings: The physician reviewer found that Cabral and colleagues state that, “Women with increased breast size experience symptoms such as pain in the neck, shoulders and lumbar spine, headache, intertrigo in the inframammary fold, difficulty in performing daily activities, paresthesia in the hands, difficulty in exercising, low self-esteem, and body dissatisfaction.” The American Society of Plastic Surgeons (ASPS) states that reduction mammaplasty authorization 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 of the following signs: (1) chronic breast pain due to weight of the breasts; (2) intertrigo unresponsive to medical management; (3)…

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reduction surgery.In this case, the patient complains of back and neck pain and has a history of a prior breast reduction. There is no report of chronic breast pain due to weight of the breasts, intertrigo unresponsive to medical management, thoracic kyphosis, upper extremity paresthesia, headache, or congenital breast deformity. Furthermore, while there is mention of shoulder grooving, it is not documented on physical exam or supported by photographs of the patient. Because there are less than two quality of life signs, the requested service would not be considered medically necessary according to ASPS criteria.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a breast reduction procedure. Signs and symptoms of macromastia as the most important factor for determining whether a breast reduction surgery is medical necessary. The presence of two or more symptoms occurring most or all of the time, including rashes, back and neck pain, arm pain, and numbness, differentiates patients with breast hypertrophy from those without breast hypertrophy. There is a lack of evidence in the records submitted supporting these symptoms.

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