Reduction Mammaplasty denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reduction mammaplasty, panniculectomy, and abdominoplasty for treatment of her medical condition. Findings: The physician reviewer found that the request for reduction mammaplasty and panniculectomy are medically necessary for treatment of the patient’s medical condition. The patient presents with well-documented signs and symptoms of significant symptomatic macromastia and a symptomatic lower abdominal pannus that has failed reasonable conservative dermatologic management. Her photographs, multiple examinations and recommendations from multiple physicians have supported her condition and she would likely have functional improvement from surgical intervention in the form of bilateral breast reduction and lower panniculectomy.

A 30-year-old female enrollee has requested a plastic surgeon consultation for therapeutic reduction mammaplasty for treatment of her chronic back pain. Findings: The physician reviewer found that based on the patient’s complaints and the medical records provided, there is sufficient documentation that a functional deficit from breast enlargement may be present. Symptomatic macromastia is documented as the patient’s ADLs are affected and physical therapy has been attempted. As confirmed by the Health Plan, shoulder grooving from bra straps is documented. As stated from the American Society of Plastic Surgeons (ASPS), “Based on the results of Level I and II Evidence, reduction mammaplasty has been proven effective at reducing macromastia related symptoms and improving postoperative quality of life”.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast reduction and/or trunk lipectomy. With regard to the requested breast reduction, researchers stated that reduction mammaplasty 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 signs such as chronic breast pain due to the weight of the breasts, shoulder grooving, intertrigo unresponsive to medical management, headache, or congenital breast deformity. The records document that this patient complains of back, shoulder, and neck pain. However, there is a lack of documentation of shoulder grooving by physical examination or by photographs.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for reduction mammaplasty. Findings: The physician reviewer found 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 (due to weight on the anterior chest wall and compression of the brachial plexus), difficulty in exercising, low self-esteem, and body dissatisfaction.” Per the American Society of Plastic Surgeons (ASPS), reduction mammaplasty should be based on documentation of the severity of the symptoms of macromastia and impact on health-related quality of life. The ASPS states that patients with symptoms of macromastia and at least two confirmed quality of life signs are candidates for reduction mammaplasty.

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