Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast implant removal services performed.Findings:  The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service.Preoperative factors associated with increased risk of surgical site infection (SSI) common to all breast surgeries include elevated body mass index, diabetes, smoking, postmenopausal status, prior breast operation, steroid therapy, lymph node resection, preoperative chemotherapy, chest wall radiation, and increased American Surgical Association class. Intraoperative factors associated with increased risk of SSI include duration of the operation, lymph node dissection, higher amount of blood loss, and need for surgical drains. Infection rates among reconstruction surgeries are significantly higher than primary breast augmentation procedures. Among women undergoing breast reconstruction, additional factors associated with infection include receipt of radiation therapy or adjuvant chemotherapy, longer operative times with two surgical teams, and lymph node dissection. The onset of late infection extends from a few months to several years after breast implant introduction. In some cases, infection occurs only with general discomfort and fatigue. Pain and erythema are present in a high percentage of patients. An ultrasound scan can show periprosthetic fluid in order to identify the size and location of the infection and its relationship with the implant. However, an ultrasound scan does not show whether the periprosthetic fluid is infectious. If the patients condition worsens or does not improve within two days, it may be necessary to remove the implant and microbiologically analyze the material removed. In general, patients with systemic infections require implant removal. In this case, the patient presented with findings consistent with a late infection of her implant. Ultrasound-guided aspiration was initially performed and she was placed on appropriate antibiotics. However, her breast worsened despite antibiotic therapy and aspiration. Therefore, implant removal was necessary for treatment of an emergency medical condition. Thus, the patient received emergency medical services on the date of service at issue.Final Result: The reviewers determined that the patient received emergency medical services on the date of service at issue. Credentials/Qualifications: Physician reviewer is board certified in 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.