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Gigantomastia, mammareductionplasty and cost coverage

A supply with a bilateral #mammareductionplasty to be accomplished stationarily can be necessary after comprehensive appreciation of medical findings for the relief of #orthopedic health impairments existing for many years in the sense of the section 27 para. 1 sentence 1 #SGB V (see #LSG der Länder Berlin und Brandenburg - #LSG of the countries Berlin and Brandenburg, judgement of 01.03.2022 - L 26 KR 227/19, openJur 2022, 8407, https://openjur.de/u/2394490.html, https://oj.is/2394490). The prerequisite for this is that a surgical #breast reduction after unsuccessful exhaustion of all conservative therapy measures and despite the risks associated with an #operation is the only promising treatment for the relief of long-standing complaints and only the measure to be carried out as an inpatient causes a sustainable improvement of the #symptomatics. In the prognosis decision required in this respect, the #study situation on the positive effects of an intervention on the complaints in the postural and musculoskeletal system must be taken into account. As ultima ratio, the surgical intervention must contribute to #relieving the symptoms.

According to section 27 para. 1 sentence 1, sentence 2 No. 5 in conjunction with section 39 para. 1 #SGB V, insured persons will be entitled to #hospital services, if these are necessary to recognize or cure a disease, to prevent its aggravation or to alleviate symptoms. A #mammareductionplasty for the treatment of orthopedic conditions requires a serious disease of the #spine, the unsuccessful exhaustion of all conservative orthopedic treatment measures and a probability of success bordering on certainty.

The starting point for these criteria is #gigantomastia with more than 1500 cc per side and a #total breast weight of about 4 kg. The #gigantomastia does not go however for itself yet with an impairment of the #body function and is thus isolated regarded no illness in the sense of the section 27 #SGB V. However, if orthopedic complaints occur with severe #head, #neck, #shoulder and #back complaints, #cervical spine blockages and painful #muscle tension in the #shoulder-neck region, a different assessment will be indicated. Indications of the tensile load of chest weight on the shoulders are noticeable #cord lines of a bra. This tensile load negatively impacting the #shoulder and #neck region can be associated with chronic overuse in the #neck, #shoulder, and #back, as well as cause #body malposition and painful #myogelosis. Chest pain and numbness in the arms can also be typical #complaints of #gigantomastia.

In the absence of sufficiently effective conservative treatment options and expected resection weights of at least 1 kg per side, it can be assumed that a bilateral #reductionplasty will alleviate these complaints and significantly improve the quality of life. With a #breast weight of 4 kg in total, symptom relief by #physiotherapy is not expected.

However, #obesity with a #BMI of 30 or more is likely to result in a requirement by the courts for #weight reduction, unless there is a severe disproportion between breast and physique above a limit of 2% of body weight per breast.

#Intertrigo and #eczema as well as psychological discomfort caused by a #gigantomastia do not justify a claim for #cost coverage for a #mammareductionplasty, according to the Senate. Dermatological complaints can be countered with optimal #skin care and meticulous #body hygiene, so the judges. As far as psychological consequences are concerned, it ought to be only a claim for psychiatric or psychotherapeutic treatment. In my opinion, both appear questionable. #Intertrigo and #eczema are known to be persistent diseases, which can be associated with #pain or #itching and can become chronic. Their cause - like that of psychological stress - is physical, which can be immediately eliminated by #mammareductionplasty. To refer #patients to #care and #hygiene products (as far as can be seen, the #Senate does not adress reimbursable #corticosteroid-containing ointments, which could also be considered in the case of an inflammatory #skin disease) or to #psychotherapy and #psychopharmacology does not get to the root of the problem and is economically nonsensical. While #care and #hygiene products are monetarily charged to the female #patients (a rogue who thinks evil of it), #psychotherapies and #psychopharmaceuticals are reimbursable in principle. Long-term suffering paths are not to be excluded by this - however strengthened - #jurisdiction. This cannot be in the sense of practitioners in #gynaecology, #dermatology, #psychiatry and #psychotherapy. At least the requirements of #orthopedics are taken into account by the Senate.

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