Issued and entered Ocober 3, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On August 2, 2002, Petitioner xxxxxxxxxxxxx filed a request for external review with the Commissioner of Financial and Insurance Services (Commissioner) under the Patient’s Right to Independent Review Act, MCL 550.1901 to MCL 550.1929. The material was reviewed by the Office of Financial and Insurance Services (OFIS) and was accepted for review on August 9, 2002. A determination on medical issues was required. The Commissioner assigned the case to National Medical Reviews (NMR), an independent review organization (IRO). The Commissioner directed National Medical Reviews to obtain the opinion and recommendation of a medical expert. The IRO completed its review on August 21, 2002, and sent it to OFIS. A copy of the report is attached.

II
FACTUAL BACKGROUND

Petitioner is a member of Care Choices HMO under the Subscriber Certificate of Coverage purchased by her employer. She is 5’ 1” tall and weighs 101 pounds. She wears a DD cup bra size, which is extremely large for a small body frame. She has a history of back pain and she has severe pain in her breasts from fibrocystic disease in the breast tissue. Medical records also show breast tissue calcifications.

Petitioner’s former primary care physician referred her to a plastic and reconstructive surgeon in Bloomfield Hills. The surgeon submitted a letter, dated January 31, 2001, seeking pre-authorization to perform Bilateral Reduction Mammoplasty. The surgeon indicated the distance from Petitioner’s sternal notch to the nipple was 27 cm on both sides. He stated at least 700 grams of tissue from each breast should be removed. He also noted Petitioner would benefit greatly from breast reduction as treatment for severe fibrocystic breast disease.

In Year 2001 Care Choices approved a Reduction Mammoplasty procedure for Petitioner, but she did not go through with the surgery because she was scared. In 2002, Petitioner was mentally and physically ready to have the surgery. She applied for a new approval of the surgery, but Care Choices denied the request in its final adverse determination letter dated July 11, 2002. The letter alleged the proposed Reduction Mammoplasty did not meet the Care Choices medical guidelines for the condition.

III
ISSUE

Whether Care Choices HMO (Care Choices) properly denied Petitioner approval and coverage for Reduction Mammoplasty?

IV
ANALYSIS

PETITIONER’S ARGUMENT

Petitioner argues the breast reduction surgery is not for cosmetic reasons. She believes the surgery is medically necessary, in part, to remove the diseased tissue that causes severe chest pain. She also believes the surgery would also help her back and neck pain.

	Letters from Petitioner’s Physicians
	1.	In a June 11, 2002, letter, the Petitioner’s surgeon stated she suffered from fibrocystic disease of the breasts for an extended period of time. The disease caused her continuing difficulties. The surgeon also noted, “she has significant back and shoulder pain related to the somewhat large size of her breasts in comparison to her body habitus.” He concluded by saying, “I believe the patient would benefit greatly from this procedure [breast reduction] in light of her ongoing difficulties.”
	2.	In a July 2, 2002, letter from a second evaluating physician, it was noted Petitioner had spinal pain in the thoracic area and in the lower back. The pain had existed for quite some time and had gotten progressively worse. Although Petitioner did not have any numbness, tingling, or significant parenthsias, the pain nevertheless limited her daily activities. He stated the Petitioner had developed some degree of mild thoracic kyphosis and he agreed with the recommendations of the plastic surgeons that the Petitioner would benefit from reduction mammoplasty because of the chronic nature of her back pain. He said with surgical reduction of her breast size, she would find relief of some of her symptoms.

CARE CHOICES HMO ARGUMENT

The Care Choices final adverse determination relied on limitations in the Certificate of Coverage and certain HMO medical guidelines (Medical/Surgical MS-1, Reduction Mammoplasty). The final adverse determination stated in part:

On July 8, 2002, the Member Reconsideration Committee upheld the original adverse determination for the following reasons:

• This therapeutic intervention (reduction mammoplasty) does not meet Care Choices HMO medical guidelines for this condition.
  * * *
  Therefore, Care Choices HMO will not pay for the services, as they are benefit exclusion under the medical plan that your employer group purchased.

Care Choices argues the surgery is not medically necessary. Care Choices asserts the reduction mammoplasty does not meet medical guidelines for Petitioner’s condition. Care Choices said “…a previous authorization request dated March 1, 2002, was also denied due to the lack of clinical documentation showing any improvement in fibrocystic breast disease following reduction surgery…” Care Choices emphasizes there is no medical documentation that reduction mammoplasty is beneficial in the treatment of fibrocystic breast disease.

Care Choices reviewed the medical reports submitted by Petitioner’s specialists. The diagnosis ranged from neck and back pain to fibrocystic breast disease. Care Choices notes there is no documentation in Petitioner’s medical records that conservative treatments were tried to alleviate neck or back pain, or for therapeutic intervention for pain.

A copy of the Care Choices Medical Policy (Medical/Surgical MS-1, Reduction Mammoplasty) was submitted for review. It states, in part:

Care Choices claims the criteria for coverage for the requested surgery had not been met in this case.

INDEPENDENT REVIEW ORGANIZATION’S (IRO) RECOMMENDATION

A practicing, board-certified physician in Internal Medicine and Endocrinology reviewed this case. The expert physician is experienced and qualified to treat patients like the Petitioner. The expert recommended reversing the Care Choices denial.

The expert’s report specifically referenced the following information: a. letters to Care Choices from Petitioner’s plastic surgeon, her general surgeon, and her physical medicine and rehabilitation specialist; b. previous denial letters, and the guidelines for pre-authorization for reduction mammoplasty; c. medical records from Petitioner’s breast biopsies, laboratory work, pathology reports and operative reports. The reviewer said that Petitioner’s complaints of severe breast, neck and back pain from her large pendulous breasts have been present for greater than one year. Petitioner has had an evaluation that determined there is no other cause for the pain besides the size of her breasts. The treating plastic surgeon said the proposed amount of tissue resection per breast exceeds that required for coverage. Petitioner’s sternal notch to nipple distance exceeds the requirements stated in the Care Choices medical guidelines. Petitioner has documented conservative therapy with appropriate brassiere support without relief.

The expert physician concluded Petitioner's symptoms would make her eligible for covered benefits under Care Choices Certificate and (Medical/Surgical Policy MS-1, Reduction Mammoplasty). The expert physician therefore recommended reversing the adverse determination denying authorization and coverage for Petitioner’s Bilateral Reduction Mammoplasty Surgery.

COMMISSIONER’S REVIEW

The Commissioner reviewed all of the documents and arguments presented by the parties. The Commissioner finds the Petitioner submitted sufficient evidence of medical necessity for the mammoplasty surgery. The evidence shows Petitioner suffers significant breast pain and discomfort. She also experiences neck and back pain, undoubtedly caused by excessive breast tissue.

Moreover Petitioner has fibrocystic breast disease. The evidence demonstrates the condition causes Petitioner physical difficulties, including significant breast pain. Her physicians concluded the condition would likely cease or decrease in severity if she has the surgery. These medical opinions are contrary to Care Choices’ assertion that there is no medical documentation supporting the surgery as the standard treatment for fibrocystic breast disease.

The Commissioner agrees with the medical opinions of the Petitioner’s physicians and the IRO. These opinions focus on objective medical problems and symptoms that are not “cosmetic” in nature. The well-documented symptoms are consistent with the Care Choices Medical Guidelines for Reduction Mammoplasties. As a result, the Commissioner finds the Petitioner has met the medical criteria stated in the Care Choices Guidelines and the proposed surgery is indeed medically necessary.

V
ORDER

Therefore, it is ORDERED that the final adverse determination issued by Care Choices on June 11, 2002, is reversed. Care Choices is responsible for coverage for the Petitioner’s bilateral reduction mammoplasty because it is medically necessary.

If the Petitioner’s surgery has not yet been performed, Care Choices shall process the claim timely and within the normal course of its claim handling process. If the surgery has been performed as of the date of this Order, Care Choices shall make proper payment within sixty days from the date of this Order and it shall provide the Health Plans Division of the Office of Financial and Insurance Services proof of payment within fourteen days of payment. To seek enforcement of this Order, Petitioner must report any complaint regarding authorization or payment to the Office of Financial and Insurance Services, Health Plans Division, by calling the toll free telephone number: 1-877-999-6442.

This is a final decision of an administrative agency. Under MCL 550.1915, MCL 600.631, MCR 7.101 and MCR 7.104, 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.