Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast implant removal.This patient has expressed an interest in bilateral implant removal, bilateral capsulectomies, and bilateral mastopexies. She has bilateral large cosmetic saline breast implants, significant breast ptosis over the implants, and an asymmetric superior location of her left implant. The presence of the patients breast implants is not a functional disability. Removal of the cosmetic breast implants would be a cosmetic procedure. There is no documentation that she has a Baker Grade IV capsular contracture on her left breast. Photographs document superior migration of her left breast implant with some degree of capsular contracture on the left side, but there is no visible distortion associated with a Grade IV contracture. Breast implant contracture is a known known complication of cosmetic breast augmentation surgery, and in the absence of a confirmed Grade IV contracture has no functional disability. Breast capsulectomies are not medically necessary for treatment of this patient. She has bilateral breast ptosis, which presents no functional disability. A bilateral mastopexy to lift the ptotic breasts is not medically necessary. For these reasons, the requested bilateral breast implant removal is not medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. The presence of cosmetic breast implants is not the result of a congenital defect, a developmental abnormality, trauma, infection, tumor or disease. The presence of capsular contracture around cosmetic breast implants is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. Breast ptosis is a normal result of aging and is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. In addition, the requested procedure is not being requested to address a functional deficit and would not make a more than minimal improvement in the patients appearance. All told, the requested bilateral breast implant removal  is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.