Reduction Mammoplasty denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for reduction mammoplasty. The Health Plan has denied this request and reported that the services at issue were not medically necessary and were not reconstructive in nature. At issue in this case is whether reduction mammoplasty was medically necessary to treat the patient’s medical condition.Findings: The physician reviewer found that the American Society of Plastic Surgeons (ASPS) states that reduction mammoplasty 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: chronic breast pain due to weight of the breast, intertrigo unresponsive to medical management, upper back, neck, and shoulder pain, unspecified, thoracic kyphosis, acquired, shoulder grooving from bra straps, upper extremity par…

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.

Where the denial was upheld

The patient is a 30-year-old female who has a complex history of low back pain due to a motor vehicle accident, but also has upper back, neck and shoulder pain that may be due to her large breasts. She has requested authorization and coverage for breast reduction surgery. She is obese and her request was denied on the basis that her body mass index (BMI) exceeds 30. At issue is whether breast reduction surgery (reduction mammoplasty) is medically necessary for treatment of the patient’s medical condition.This patient’s musculoskeletal symptoms may or may not be due to macromastia, but referral to a plastic surgeon to make this determination is warranted. The patient’s request for a breast reduction was denied on the basis that the patient is obese. Weight loss however, does not improve the symptoms of macromastia.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast reduction surgery. The American Society of Plastic Surgeons (ASPS) state that reduction mammoplasty is based on documentation of the severity of macromastia symptoms and impact on health-related quality of life. Documentation should include evidence at least two symptoms such as intertrigo unresponsive to medical management, headache, upper back, neck, and shoulder pain and/or shoulder grooving from straps. Additional indications include chronic breast pain due to weight of the breasts, kyphosis, upper extremity paresthesia, and congenital breast deformity. The ASPS has indicated the decision to perform reduction mammoplasty considers a patient’s symptoms and provider’s assessment of the likelihood of benefit.

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