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

The patient has requested authorization and coverage for right breast reconstruction surgery and left breast mastopexy and fat graft. The records provided for review document that this patient underwent breast reconstruction with a satisfactory result. The records do not report any pain or symptomatic capsular contracture. MRI revealed a probable asymptomatic intracapsular silicone implant rupture on the left breast. The patient has an animation deformity on tensing her pectoralis muscles. This is universally present in subpectoral implant placement, both reconstructive and cosmetic, and does not constitute a physical deformity of a mastectomy. Medical literature reports that subpectoral prosthesis placement with partial muscle coverage, with or without acellular dermal matrix, is currently the standard technique for implant-based breast reconstruction. However, the authors cautioned that elevation of the muscle has introduced its own set of problems, including animation deformities caused by muscle contraction, chest tightness, pain, and muscle spasm. Researchers found that, animation deformity is a direct consequence of subpectoral implant placement for breast reconstruction following mastectomy. Current treatment options ameliorate but do not address the source of the problem. Thus, the bilateral animation deformity is not actually a deformity. It is a side effect of all submuscular breast implants, both cosmetic and reconstructive, in that tensing the pectoral muscles strongly causes the breast implants to flatten somewhat. This is an expected effect of the surgery, not a complication. Based on the records, the approved surgery of capsulotomy and replacement of the left breast implant for probable intracapsular implant rupture is medically necessary. It is for the treatment of a complication of a breast reconstruction. However, the requested right breast reconstruction surgery is not medically necessary for the treatment of this patient based on lack of evidence of implant rupture, and documentation of an expected effect of surgery rather than a complication that requires re-surgery. With regards to left breast mastopexy, there is no functional component present. Therefore, left breast mastopexy is not medically necessary. Fat grafting was proposed at a subsequent procedure if a bilateral breast reconstruction were performed with the implants being transferred from a retropectoral (submuscular) position to a prepectoral position. As a secondary breast reconstruction has been determined to be not medically necessary, future fat grafting is not medically necessary.The appearance is normal, and the requested services would provide only a minimal improvement in appearance. Given these findings, the requested right breast reconstruction surgery and left breast mastopexy and fat graft are not reconstructive in nature. 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.