Breast Augmentation for GU/ Kidney Disorder: 50.0% of denials overturned
In 6 California IMR decisions from 2020 to 2024, reviewers overturned 3 (50.0%). In the last five years: 25.0% of 4. 6 were medical-necessity disputes.
By year (last five)
| Year | Decisions | Overturned |
|---|---|---|
| 2021 | 2 | 50.0% |
| 2023 | 1 | 0.0% |
| 2024 | 1 | 0.0% |
What the findings mention
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mastopexy (CPT 19371) and breast reduction (CPT 19318). Findings: The physician reviewer found that Cabral and colleagues state 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, …”
“Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for breast surgery. Authors state that the characteristics of tuberous breast deformity include a “contracted skin envelope, a reduction in breast parenchyma of the lower medial and lateral quadrants, a constricted breast base, abnormal elevation of the inframammary fold, herniation of the breast into the areola with …”
“The patient has requested authorization and coverage for left breast oncoplastic reconstruction and contralateral right reduction mammoplasty. The patient presents significant abnormalities related to non-malignant disease. Her provider has recommended breast surgery to alter the contour of the breast given the severity of the deformity. Given the size of this area of enhancement, the patient would have significant deformity following …”
And one the reviewer upheld
“The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast reduction. One study noted that “Breast hypertrophy is a condition that may give rise to both physical and psychosocial symptoms, including muscle pain, such as back and shoulder pain, headache, postural changes, bra strap grooves, intertrigo, inability to participate in …”
- California only: these are decisions by independent reviewers under California's IMR program (plans regulated by the Department of Managed Health Care). Other states and self-funded employer plans use different reviewers and rules.
- Selection: only denials that a member took all the way to IMR appear. Most denials are never appealed, and the ones that reach an external reviewer are not a random sample.
- Overturned means the reviewer disagreed with the plan; it does not mean the treatment worked or that a similar request will be approved.
- Argument tags are keyword matches on the reviewer's findings. They describe what the findings mention, not why the case was decided.
- Categories are DMHC's own labels (treatment sub-category and diagnosis category); 'Other' is a catch-all and is excluded from rankings.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, Trend (CHHS Open Data). Public California government data; Apellica's aggregates and tags are CC BY 4.0.
Questions
How often were Breast Augmentation denials for GU/ Kidney Disorder overturned?
In 6 California IMR decisions from 2020 to 2024, reviewers overturned 3 (50.0%). In the last five years: 25.0% of 4. 6 were medical-necessity disputes.
What should an appeal document, based on these findings?
Whatever the plan's criteria ask for, shown in the record: the treatments already tried and their results, contraindications to the plan's preferred option, the guideline or evidence that supports the request, and the treating clinician's reasoning written to the criteria. The tag table shows which of these the reviewers mentioned most in overturned cases.
Does a California IMR result apply to my plan?
Only California plans regulated by the Department of Managed Health Care go to IMR. Other states and self-funded employer plans use different reviewers, but they weigh the same things.
Independent reviewers reverse plans when the record answers the criteria. Upload the denial letter; a senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.