Court rules for breast reduction
Agency denied procedure despite doctors' urging, Del. justices say
By ESTEBAN PARRA
The Delaware Department of Health and Social Services erred when it required a Medicaid patient to lose weight before approving her breast reduction surgery, the Delaware Supreme Court ruled.
The court said DHSS failed to consider all of the evidence in Kandase Urban's case as well as the opinions of both of Urban's treating physicians. Justices returned the case to Superior Court, which had sided with the state agency, to enter an order in compliance with the higher court's ruling.
"I'm happy," said the 19-year-old Urban, who is studying to become a certified nursing assistant. "I'm excited because it's been two years of fighting them and they kept saying no."
Urban, who wears a size 42DDD bra, said she would like to reduce her breasts to at least a D cup.
"I'm not proud of my chest and don't want them," said the New Castle woman, who at 5 feet, 2 inches tall weighed 198 pounds when she originally sought the surgery. "I'd like them to be smaller so I can participate in a lot of the activities that I can't right now. I want to be able to run and be normal and keep the pressure off my back."
Urban said her breasts prevent her from exercising, completing house chores without exhausting herself, and even sleeping properly.
"It's not as great as you think it is," she said.
DHSS did not comment.
Dr. Lawrence Chang, a plastic surgeon, found that Urban suffered from chest and back pain, as well as rashes, shoulder grooving and depression because of her breasts. Chang said breast reduction surgery would benefit Urban, but recommended she lose about 40 pounds first.
Following the Chang visit, Urban asked the state for breast reduction surgery in December 2004.
Delaware Physicians Care Inc., which administers the state's Medicaid program, turned her down the next month, saying Urban was obese and "weight reduction would likely be in her best interests as well as instrumental in reducing breast size."
It also said the surgery did not meet Delaware's definition of a medical necessity.
Urban lost 15 pounds by May 2005, when she visited Chang, who noted that despite losing weight, her breast size and symptoms remained the same.
"I feel that having the 15-pound weight loss should allow a better result from a bilateral reduction mammoplasty, and I feel that she is at a reasonable weight at this present time to proceed with surgery," Chang wrote.
Two weeks after visiting Chang, Urban got a second opinion from another plastic surgeon, Dr. Benjamin Cooper, who agreed that she needed breast reduction surgery. Cooper also explained that women with unusually large breasts rarely lose significant amounts of weight prior to surgery.
Despite this, Delaware Physicians Care said Urban did not qualify and recommended the state hold off on paying for the surgery until she went down to 160 pounds.
Urban appealed the decision to Superior Court, which sided with the state, noting that the doctors agreed Urban would benefit from the weight loss before surgery. The lower court also said that surgery had not been denied, only postponed.
In overturning that ruling, the Supreme Court cited a federal appeals court decision involving Social Security disability benefits.
In its decision, the Supreme Court said DHSS must give "substantial weight" to the opinions of treating physicians and less to those who have not seen the patient. The court also said DHSS must explain its reasons for rejecting any expert evidence and should not substitute its expertise for the competent medical evidence.
"The record establishes that DHSS failed to adhere to these standards in affirming the denial of Urban's surgery," Justice Carolyn Berger wrote in the decision handed down last week. "DHSS never even mentioned the fact that both Chang and Cooper opined that surgery, without additional weight loss, was medically necessary. Thus, it appears that DHSS not only failed to give any deference to the competent medical evidence, but also it failed to consider that evidence at all."
Urban's attorney, MaryBeth Musumeci, said the case was an important one for anyone seeking medical treatment.
"It's about going to the doctor and having your doctor evaluate you and make a professional recommendation about what is the best treatment and being able to get that treatment paid for by your health insurance," she said. "This is not an elective cosmetic procedure. This is something her doctors thought she needed to address."
Contact Esteban Parra @ 324-2299 or eparra@delawareonline.com.