Issued and entered November 20, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On July 15, 2002, Dr. XXXXXXXX filed a request for external review with the Commissioner of Financial and Insurance Services (Commissioner) under MCL 550.1901 et seq., the Patient’s Right to Independent Review Act. The request was filed on behalf of Petitioner, XXXXXXXXX. After a review of the material submitted, the Commissioner accepted the request.

A determination on medical issues was required. The Commissioner assigned the case to Permedion, an independent review organization (IRO). The Commissioner directed Permedion to obtain the opinion and recommendation of a medical expert.

On August 1, 2002, Petitioner submitted additional information for review and the material was sent to the IRO. The IRO completed its review on August 6, 2002, and sent it to the Office of Financial and Insurance Services (OFIS). A copy of the report is attached.

II
FACTUAL BACKGROUND

On November 21, 2001, Petitioner’s plastic surgeon submitted a request to Fortis for a predetermination of benefits for a bilateral breast reduction for Petitioner. The surgeon stated Petitioner is complaining of heaviness of the breasts, neck and shoulder tenderness, sweating and maceration of the inframammary line, and shoulder grooving. Petitioner has never had a mammogram and has no family history of breast malignancy. The physical examination showed large breasts, no breast masses, and no axillary lymphadenopathy. She is 5’3” with a bra size of 40DDD.

The surgeon provided Fortis with a picture of Petitioner’s anterior chest wall and stated he would resect more than 500 grams from each breast, and in all probability, the resection would be close to 1,000 grams. This is consistent with the standard criteria listed in a position paper on Reduction Mammoplasty, prepared by the American Society of Plastic and Reconstructive Surgeons, Inc. This position paper was provided to Fortis for review.

Fortis denied the request, alleging the procedure was not medically necessary. The clinical rationale for the decision was based on the fact the Petitioner is morbidly obese with a BMI of 46. Fortis stated that, in light of the strong correlation between obesity and symptoms of back pain, the complaints of back and neck pains cannot be determined to be solely related to her breast size. Following internal review, Fortis issued its final adverse determination on June 6, 2002.

III
ISSUE

Did Fortis comply with the terms of its Certificate of Insurance when it denied Petitioner’s request for a bilateral reduction mammoplasty?

IV
ANALYSIS

Petitioner’s Argument

Petitioner asserts that Fortis should cover bilateral reduction mammoplasty because it is a medically necessary procedure. She alleges that, when Fortis denied the requested procedure based on the correlation between obesity and back pain, Fortis ignored her other symptoms, which are separate from her back pain.

In addition, Fortis ignored the clinical practice guidelines of the American Plastic Surgery Society (guidelines). Petitioner asserts that she meets the criteria for bilateral reduction mammoplasty outlined in the guidelines and therefore should receive coverage for the surgery.

Fortis Insurance Company Argument

Fortis concludes the bilateral reduction mammoplasty is not medically necessary and does not meet their internal guidelines.

Fortis stated:

The clinical rationale for the decision is as follows:

The Patient’s BMI is 46kg/mg. Obesity is defined as BMI >27.3kg/m2 and frequently contributes to complaints of low back and neck pain. The patient’s complaints of back and neck pain cannot be exclusively related to her breast size.

Under the terms, conditions and limitations of Petitioner’s coverage, medical necessity is defined as:
Services, supplies, or treatment (including medication), which, as determined by us:

1. are appropriate and consistent with the diagnosis, and are in accordance with accepted medical practice and federal government guidelines, including, but not limited to, the guidelines of the Health Care Financial Administration (HCFA);
2. can reasonably be expected to contribute substantially to the improvement of an illness or injury and are not for custodial care;
3. are not excluded under the policy;
4. are not experimental or investigational services;
5. are provided in the least intense setting without adversely affecting a coverage person’s condition or the quality of medical care provided; and
6. are not solely for the covered person’s convenience, or the convenience of the covered person’s family or physician.

Independent Review Organization (IRO) Recommendation

The expert physician who reviewed this case is a board certified Plastic Surgeon. The medical expert reviewed all documents and arguments presented by the parties. The expert concluded that:

• The Petitioner has documented symptomatic bilateral macromastia;
• Regardless of Petitioner’s morbid obesity, the photographs and medical records support this diagnosis;
• breast hypertrophy has no other modality of treatment than a reduction mammoplasty;
• bilateral reduction mammoplasty is medically necessary because it is the appropriate treatment for Petitioner’s condition.

Commissioner’s Review

The Respondent did not challenge the diagnosis that Petitioner suffers from the condition known as breast hypertrophy. Respondent did not disagree that the treatment sought is an appropriate remedy for the condition diagnosed. Respondent simply asserts that two of the Petitioner’s symptoms, back pain and neck pain, “cannot be exclusively related to her breast size.” In effect, Respondent argues that it will only pay for those treatments which address symptoms which have a single source. This principle has no support in any definition of medical necessity, including Respondent’s own definition quoted above. The Commissioner concurs with the IRO’s assessment of this case.

V
ORDER

The final adverse determination of Fortis Insurance Company is reversed. Fortis shall approve and pay for Petitioner’s bilateral reduction mammoplasty.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.