Mastopexy 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: The patient has requested authorization and coverage for mastopexy, excessive skin removal of the hip, panniculectomy, and/or abdominoplasty. The records document that this patient presents with a history of weight loss after gastric bypass surgery four years ago. Per the provider, the patient has lost 150 pounds and is currently 130 pounds with a height of 4 feet 11 inches. The patient is noted to have severe skin redundancy. The patient complains that the excessive skin interferes with her ability to perform activities of daily living. However, the records lack documentation of a functional issue due to the presence of excessive skin on the breasts or pannus. Moreover, the provider did not report adequate trials and failure of medications to treat rashes to support an indication for panniculectomy.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for mastopexy. Researchers discussed a patient who sustained bilateral breast implant rupture following elective electrical cardioversion for atrial fibrillation. The researchers reported that capsular formation with dense muscular attachments is a known complication with breast implants, while breast implant rupture is uncommon and may be associated with “significant health and cosmetic consequences.” Researchers noted that that surgical intervention for “diagnosed or symptomatic ruptured silicone breast implants is removal, generally including a complete capsulectomy.” In addition, for intracapsular rupture, “explantation involves removal of the implant and any free silicone, capsulectomy and replacement of the implant if the patient wishes.” Researchers state that, “mastopexy and mastopexy-augmentation…

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