Breast Reduction Surgery 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 breast reduction surgery and reconstruction. According to researchers, reduction mammaplasty is a highly effective procedure for the treatment of symptomatic macromastia. One study investigated whether small-volume resections in reduction mammoplasty produced symptomatic improvement. The authors concluded that “reduction mammaplasty has a positive impact on a range of symptoms, even with lower volume resections and regardless of body surface area-calculated adjustments.” In this case, the patient has a history of chronic bilateral thoracic and lumbar pain and symptomatic macromastia. The patient reported back pain, shoulder pain, headaches, postural changes, intertrigo, inability to participate in exercise activities, and poorly fitted clothing.

A 48-year-old female enrollee has requested bilateral breast reduction surgery for treatment of her macromastia. Findings: The physician reviewer found that the patient is documented in the medical records to have macromastia, which is abnormal enlargement of the breasts. Her photographs clearly demonstrate significant macromastia. Her very pendulous breasts were noted to significantly limit normal breast/chest exam. According to the medical records, the patient’s cup size was reported as DDD which is greater than size DD, which the Health Plan requires. In addition, the patient is documented to have significant complaints of pain due to her large breasts with exacerbation of her degenerative disc disease from the pressure of her bra. She is documented to have right shoulder impingement syndrome and sensory changes of the hand.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) breast implant removal surgery and (2) breast reduction surgery. In a study of breast implant complaints, complications, and explantations between 2003 and 2015 including 448 patients, Pool and colleagues report, “Overall, 18% of the implants resulted in postoperative complaints, with discomfort or pain being the most common complaint (12%), significantly more frequent in reconstructive cases and significantly associated with subglandular placement in cosmetically augmented breasts. Physical examination revealed, in 14%, one or more postoperative complications, with capsular contracture being the most common complication. A total of 12% of the implants were eventually explanted within a median time of 568 days.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast reduction surgery. Cabral and colleagues report, “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 (due to weight on the anterior chest wall and compression of the brachial plexus), difficulty in exercising, low self-esteem, and body dissatisfaction.”According to the American Society of Plastic Surgeons (ASPS), reduction mammaplasty may be recommended 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: chronic breast pain due to weight of the breasts; intertrigo unresponsive to medical management; upper back,…

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