Breast Surgery denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast implant removal services performed.Findings: The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines “emergency services and care” as “medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility.” A screening examination in an emergency department, and any medical…

The patient is a 41-year-old woman with breast hypertrophy. She has photographic evidence of macromastia and the typical symptoms associated with severe breast hypertrophy including complaints of shoulder, neck, and back pain, bra strap grooving and intertrigo. She has requested authorization for bilateral breast reduction surgery. The Health Plan has denied her request on the basis that the requested procedure is not medically necessary for treatment of her condition.Breast reduction surgery is medically necessary for this patient. She has documented breast hypertrophy and her complaints are typical for symptomatic macromastia. The constellation of symptoms in the context of breast hypertrophy is diagnostic for symptomatic macromastia, and additional workup is not required.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast augmentation revision/reduction surgery with modifier 50, performed treatment of the enrollee, who reported lower back pain and pain between her ribs. Findings: The physician reviewer found that the patient had undergone revision of her previous augmentation with placement of smaller implants and a mastopexy. Although the patient is noted to have chronic back pain possibly related to her previous breast augmentation, the indications for the procedures were that the patient desired smaller implants and that she had severe rippling. The plastic surgery documentation did not describe a clear functional deficit related to the size of the original implants.

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral mastectomy with male chest reconstruction for treatment of the enrollee's gender dysphoria. Findings: The physician reviewer found that the surgical concept of treating breasts for purposes of female-to-male reassignment surgery is well established and documented within the community of plastic surgeons as provided in the references cited above. Each patient must be reviewed on a case-by-case basis to determine medical necessity. In this patient’s case, medical necessity for the proposed services not been adequately established in the clinical documentation provided.

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