Mastectomy denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for a mastectomy. Gynecomastia is the presence of an abnormal proliferation of breast tissue that accounts for up to 65% of male breast disorders. Gynecomastia has a broad range of causes that are classified as either physiological or pathological, although in many cases, no specific cause can be found. In a study, the authors reported that guidelines for gynecomastia state that, “gynecomastia (GM) is a benign proliferation of the glandular tissue of the breast in men. It is a frequent condition with a reported prevalence of 32 to 65%, depending on the age and the criteria used for definition.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a mastectomy procedure for removal of gynecomastia on both breasts.At issue is whether the requested mastectomy procedure for removal of gynecomastia on both breasts is medically necessary to treat the patient’s medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible?

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for mastectomy. Gynecomastia is defined as the presence of an abnormal proliferation of breast tissue in males with a broad range of causes that are classified as either physiological or pathological, although in many cases no specific cause can be found. In true gynecomastia, the breast enlargement is due to glandular breast tissue while in pseudogynecomastia, the breast enlargement is secondary to fat accumulation. Both glandular and fat tissue are present in mixed gynecomastia. Gynecomastia is to be differentiated from pseudogynecomastia, an increase in subareolar fat often related to obesity. True gynecomastia has a palpable firm disc of tissue under the nipple areolar complex.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mastectomy. The records document that this patient has gynecomastia, which is an abnormal structure of the body. However, the patient’s medical condition is not attributed to congenital abnormalities, developmental abnormalities, trauma, infection, tumors and disease. Moreover, the records do not document any health or functional problems caused by the patient’s enlarged breasts. This patient’s records do not document any concern for breast cancer. The procedure will primarily improve the patient’s appearance and therefore is cosmetic. Observation, reassurance and use of analgesics are reasonable management approaches for this patient’s condition.

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