When is breast augmentation or breast reduction medically necessary?
Aphysician prescribes a breast reduction for Andrea, a 32-year-old female who is 5 feet 1 inch tall, weighs 135 pounds, and has a body surface area (BSA) of 1.60. For several years, Andrea has complained of shoulder, back, and neck pain; bra strap grooving; and intertrigo (eczema). She wears a 34DD bra and attributes her pain and other symptoms to her large breasts. In her attempts to nonsurgically diminish her symptoms, she’s resorted to wearing support bras, taken NSAIDs, and had several years of chiropractic treatments. Yet, none of this has alleviated any of her symptoms.
Now, her plastic surgeon is recommending breast reduction: The removal of 500 grams of tissue from each breast. Is this surgery a medical necessity, supported by contemporary, peer-reviewed literature—and something for which Andrea qualifies under her medical plan?
Traditionally, both breast-augmentation and breast-reduction surgeries have been defined by health insurers as cosmetic. Some plans give precise definitions; others use less-than-precise wording. It is this uneven approach that leaves patients like Andrea uncertain. More often than not, the health insurance plan language leaves the meaning of terms like “cosmetic” unclear; so it is unclear whether reconstructive breast surgery is covered by the plan, and under what circumstances. This means that physicians are also in a gray area.
What Does the AMA Support?
Payors often have difficulty deciding the nature of breast-augmentation or breast-reduction cases, and are increasingly turning to external organizations, like independent review organizations (IROs), to help in the decision-making process. Among the guidelines that IROs and their peer-review panels use to determine if a procedure is medically necessary is the AMA’s definition of cosmetic versus reconstructive surgery.
According to the AMA, cosmetic surgery is the “reshaping of a normal part of the body to improve the patient’s appearance and self-esteem.” Reconstructive surgery, such as breast augmentation or breast reduction, is “surgery performed on an abnormal structure caused by disease, infection, congenital deformity, trauma, or tumors. It is surgery that is medically necessary and generally completed to improve the body’s function.” The AMA encourages third-party payors to use such definitions in determining what services are eligible for coverage.
Under the AMA definition, and considering her condition, it is possible that Andrea qualifies for surgery. She has symptoms consistent with macromastia (excessively large breasts). Her physician has noted her complaints of intertrigo. Shoulder, back, and neck pain, along with bra-strap grooving, are typical for this diagnosis. Her physician could strengthen the diagnosis by documenting her symptoms with high-resolution photos, should her case require a peer review or an external review. Unless her health plan rules out all breast reductions, Andrea’s best hope to relieve her symptoms is surgery.
What Does Peer Literature Support?
Research into the current literature supports her physician’s thesis and the AMA definition. In a peer-reviewed article on surgical and nonsurgical solutions to macromastia, Collins and Kerrigan conclude that, “In women presenting for surgery, nonsurgical measures including weight loss, physical therapy, special brassieres, and medications were not effective in providing permanent relief of breast-related symptoms. In contrast, both pain and overall health status were markedly improved by breast reduction, essentially restoring functional status to that of age-matched norms.”1
According to Schnur, in research on whether or not reduction mammaplasty is a cosmetic or reconstructive procedure, the volume of the reduction distinguishes cosmetic from functional breast-reduction surgery.2 Following Schnur’s criteria, and based on Andrea’s BSA of 1.60, the anticipated volume of resection for surgery that meet functional and medical necessary is 676 grams per breast, for a BSA of 1.63. At 500 grams per breast, Andrea’s proposed reduction falls below this amount; so she qualifies according to this guideline as well. The research shows more than a half-dozen peer-reviewed articles stating similar conclusions.
Based upon existing research and the AMA’s definition, it is safe to assume that other patients like Andrea, who have congenital breast deformity or who have experienced breast trauma, infection, tumors, or disease, also may qualify for medically necessary breast-augmentation or breast-reduction surgery when it is considered reconstructive.
For example, patients might have Poland’s Disease or cancer, breast drooping caused by dramatic weight loss, significant breast asymmetry, or a mastectomy. While mastectomy cases are mostly clear to payors, asymmetry may not be seen by payors as a functional issue.
What is obvious is that nonsurgical solutions did not work in Andrea’s case. Her anticipated breast resection falls within the recommendation by current peer-reviewed literature, which makes Andrea’s reduction consistent with medical necessity.
Skip Freedman, MD, is the medical director at AllMed Healthcare Management, an independent review organization (IRO) based in Portland, Ore. He is a longtime emergency room physician and practices at several hospitals in the Portland-Vancouver Metropolitan area. He can be reached at (503) 274-9916 or firstname.lastname@example.org.
1. Collins ED, Kerrigan CL, et al. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plast Reconstr Surg. 2002:109(5):1556-1566.
2. Schnur, PL, Hoehn JG, Ilstrup DM, Cahoy MJ, Chu CP. Reduction mammaplasty, cosmetic or reconstructive procedure? Ann Plast Surg. 1991; 27: 232-237.