Prior Authorization Request (Reduction Mammaplasty)

Prior Authorization Request: Reduction Mammaplasty (Medical Necessity)

(Use structured format throughout. Enter explicit dates and durations. Clearly separate patient-reported symptoms from clinician-observed findings. If an item is not applicable or not performed, document the reason rather than leaving blanks.)

Header

Patient: [Full name], DOB: [DOB], Sex: [sex], MRN: [MRN], Payer Member ID: [member ID]

Request Date: [Submission date]

Requested Date of Service: [Planned surgery date / TBD]

Requesting Provider: [Surgeon name, credentials], NPI: [NPI], [Practice name], [Address], Phone: [phone], Fax: [fax]

Payer/Plan: [Payer name], [Plan type]

Requested Procedure: [Bilateral / Unilateral] reduction mammaplasty; CPT: [CPT code(s)]; Setting: [outpatient / hospital]

Primary Indication: Symptomatic macromastia with functional impairment

Executive Summary

(This section must be reviewable in under 30 seconds. Use 4-6 bullet points.)

• Diagnosis and key symptoms: [Primary diagnosis] — [Specific symptoms: pain locations, intertrigo, shoulder grooving, paresthesias as applicable]
• Duration: [Approximate onset date or total duration in months/years]
• Functional impairment: [Concrete ADL, occupational, and exercise limitations]
• Conservative management summary: [Modalities attempted with date ranges] → [Outcome: non-response / partial response / intolerance]
• Key exam findings: [Pertinent measurements, shoulder grooving severity, skin findings, postural abnormalities]
• Planned resection estimate: Right: [estimated grams], Left: [estimated grams]; Method: [clinical estimate / BSA-based formula]; [Meets / Does not meet] payer threshold

Clinical History

(Document patient-reported symptoms attributed to macromastia. For each applicable symptom category, include onset/duration, severity, frequency, and functional impact. Omit categories that do not apply.)

Cervical/Thoracic/Shoulder Pain

• Onset and duration: [Start date and total duration]
• Severity and frequency: [Severity scale if documented], [frequency/pattern]
• Modifying factors: [Aggravating and relieving factors]
• Prior evaluations: [Imaging, consults, results] (Include only if performed)
• Functional impact: [Specific limitations in daily tasks, work, or exercise]

Upper Back Pain/Postural Strain

• Onset and duration: [Details]
• Severity and frequency: [Details]
• Functional impact: [Details]

Inframammary Intertrigo/Recurrent Dermatitis

• Onset and recurrence pattern: [Dates, frequency of episodes]
• Description: [Erythema / maceration / fissuring / secondary infection]
• Treatments attempted: [Hygiene measures, barrier creams, topical antifungals/antibiotics with date ranges]
• Response: [Partial / none; recurrence pattern]
• Functional impact: [Pain, odor, sleep disruption, activity limitation]

Shoulder Grooving

• Duration: [How long present]
• Skin changes: [Hyperpigmentation / callus / skin breakdown]
• Bra modifications attempted: [Professional fitting, wide straps, specialty garments with dates and response]
• Functional impact: [Details]

Neurologic Symptoms

• Distribution and characteristics: [Areas affected, pattern of paresthesias]
• Duration and frequency: [Details]
• Evaluation for other causes: [Exams, EMG, imaging and results] (Include only if performed)
• Functional impact: [Grip, dexterity, sleep, work effects]

Functional Impairment

(Required. Document concrete, observable limitations.)

• Activities of daily living: [Bathing, dressing, household tasks, childcare, driving — specify tasks limited]
• Occupational function: [Job role, missed work days, duty restrictions, modifications required]
• Exercise capacity: [Specific activities limited; impact on weight management or conditioning]
• Patient-reported outcomes: [Instrument name], Date: [date], Domains impacted: [summary] (Include only if administered)

Attribution Statement

[Clinician statement explicitly attributing symptoms and functional limitations primarily to macromastia, with expectation of improvement following reduction mammaplasty]

Conservative Management

(Document each modality with explicit date ranges and objective response. If a typical modality was not attempted, document the reason. If total duration is shorter than payer norms, explicitly justify.)

Supportive Garments

• Date range: [Start–End]
• Details: [Professional fitting, wide straps, specialty bras; hours/day worn]
• Response: [Symptom change]
• Why insufficient: [Persistent symptoms despite use]

Analgesics/NSAIDs

• Date range: [Start–End]
• Details: [Medication(s), dose, frequency]
• Response: [Relief duration/degree]
• Why insufficient: [Incomplete relief / side effects / contraindication]

Physical Therapy

• Date range and sessions: [Start–End; number of visits]
• Focus: [Areas addressed; home exercise program compliance]
• Response: [Objective/subjective change]
• Why insufficient: [Residual symptoms/functional limits]

Dermatologic Management

(Include only if intertrigo present)

• Date range: [Start–End]
• Details: [Hygiene measures, barrier creams, antifungals/antibiotics]
• Response: [Resolution / recurrence pattern]
• Why insufficient: [Recurrent episodes despite treatment]

Weight Management

(Include only if attempted)

• Date range: [Start–End]
• Approach: [Diet, exercise, program name; supervised / unsupervised]
• Outcome: [Weight/BMI change achieved]
• Why insufficient: [Persistent symptoms despite weight change]

Specialty Evaluations

(Include only if performed)

• Service and date: [Orthopedics / Dermatology / PM&R / Other], [date]
• Key findings: [Pertinent results]
• Recommendations and outcomes: [Actions taken; response]

Modalities Not Attempted

(Include only if a typically expected modality was omitted)

• Modality: [Name]
• Reason not attempted: [Contraindication / intolerance / access barrier]

Abbreviated Conservative Course Justification

(Include only if conservative care duration is shorter than typical payer minimums)

[Clinical rationale for proceeding: refractory dermatitis, severe functional impairment, failed multiple modalities, other justification]

Physical Examination

(Objective clinician-observed findings only.)

• General: Height: [height], Weight: [weight], BMI: [BMI]
• Breast examination: [Hypertrophy severity, symmetry, skin quality, intertrigo/maceration present or absent, shoulder grooving depth and skin changes, postural findings]
• Musculoskeletal: [Cervical/thoracic paraspinal tenderness, trapezius spasm, ROM limitations] (Include only if relevant findings present)

Measurements

• Suprasternal notch to nipple distance: Right: [cm], Left: [cm]
• Nipple to inframammary fold distance: Right: [cm], Left: [cm]
• Ptosis grade: [Grade] ([Grading system used])
• Optional measurements: Areola diameter: R [cm] / L [cm]; Breast base width: R [cm] / L [cm] (Include only if obtained)
• If measurements not obtained: [Reason, e.g., telehealth visit]; Plan: [In-person measurement prior to surgery]

Photographs

(Include only if clinical photographs obtained)

• Date taken: [Date]
• Views: [Frontal / oblique / lateral]
• Findings demonstrated: [Key visible features]
• Transmission: [Secure transmission method confirmed]

Planned Procedure

• Procedure: [Bilateral / Unilateral] reduction mammaplasty
• Setting: [Outpatient / Hospital]
• Anesthesia: [General / Regional / Other]
• Resection estimate (per breast): Right: [estimated grams], Left: [estimated grams]
• Estimation method: [Clinical estimate / BSA calculation / payer threshold table]
• Payer threshold status: [Meets / Does not meet] [threshold description if applicable]
• Specimen handling: Submission to pathology per institutional protocol

Attachments

(Include dates for each document.)

• Clinic notes documenting symptoms and examination: [Date(s)] — [Attached / Available upon request / Not applicable]
• Physical therapy records: [Date range] — [Attached / Available upon request / Not applicable]
• Dermatology or PCP notes: [Date(s)] — [Attached / Available upon request / Not applicable]
• Mammogram report: [Date], [Result] — [Attached / Available upon request / Not applicable]
• Clinical photographs: [Date(s)] — [Attached / Available upon request]
• Patient-reported outcome questionnaire: [Instrument, date] — [Attached / Available upon request / Not applicable]

Closing

Authorization request: I am requesting authorization for [bilateral / unilateral] reduction mammaplasty for symptomatic macromastia with documented functional impairment.

Peer-to-peer contact: [Clinician name], Phone: [direct line], Availability: [hours/time zone]

Additional contact: [Prior auth coordinator or care team contact], Phone: [phone], Fax: [fax]

Surgeon signature: [Name, credentials], NPI: [NPI], Date: [date]