Mammoplasty denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for reduction mammoplasty. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patient’s macromastia and are not reconstructive in nature. This patient has well-documented chronic back and neck pain as well as shoulder grooving. This has significantly impacted the patient’s daily activities. The patient’s condition of macromastia is causing functional problems, and the patient is likely to benefit from reduction surgery. In this patient’s case, the requested reduction mammoplasty is consistent with standard of care. The patient has a functional problem that is directly related to significant macromastia. Breast reduction is a well-known procedure that directly addresses this functional deficit.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mastoplexy and fat grafting. The Health Plan has denied this request indicating that the requested services are not medically necessary and are not reconstructive in nature for treatment of the enrollee’s medical condition.There is support in the medical literature for the services at issue in this clinical setting. The patient is documented to have undergone medically necessary bilateral mastectomies followed by typical breast reconstruction. Based on the most recent evaluation, the patient has evidence of complications and deformities related to her medically necessary breast reconstruction. The patient has evidence of common complications associated with reconstructive breast surgery.

Where the denial was upheld

A 50-year-old female enrollee has requested bilateral revision augmentation mammoplasty (implants), bilateral mastopexy (breast lift) and bilateral breast capsulectomy for treatment of her bilateral breast capsular contracture. Findings: The physician reviewer found that bilateral mastopexy (breast lift) is not medically necessary for the patient’s condition. Mastopexy for grade II ptosis is not medically indicated unless the removed skin is affected by conditions such as intertrigo or hidradenitis. There is no documentation in the reviewed materials of any current skin condition that would be treated by mastopexy. In this patient’s case, right breast capsulectomy is not medically necessary and left breast capsulectomy is medically necessary.

The patient is a 61-year-old obese female who underwent bilateral mastectomies in 2004 for breast cancer. She was further treated with chemotherapy. She is now seeking bilateral breast reconstruction. She has been seen by a board certified plastic surgeon in the past prior to her mastectomy and in follow-up in December 2004. At that time it was proposed that the patient be seen in July or August 2005 to plan the reconstructive procedures. It was appropriately suggested that the patient lose 60 pounds if she were to be considered a candidate for a TRAM flap. There is no record of the patient being seen by the plastic surgeon since December 2004. In the interim, the patient transitioned to a new medical group in January 2005. Her reconstructive surgeon is not affiliated with the patient’s new medical group.

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