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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for mastectomy revision and/or chest reconstruction (CPT codes 19371, 19316, 19380, and/or 19340). The records provided for review document that this patient has prepectoral implants. She presents with complaints of erythema, coolness of the skin, and pain in the skin overlying her breast implants with strenuous physical activities. She underwent fat grafting in October 2019 with relief of blanching and vasospasm with activities such as playing tennis. She reports that she still experiences pain and circulation issues when she is physically active for several hours. The patient is concerned about having textured breast implants and wishes to exchange them for smooth implants. Based on the available documentation, the requested mastectomy revision and chest reconstruction are not medically necessary for treatment of this patient. Pain and circulation issues that allow intense activity and only appear after several hours of intense physical activity do not constitute a functional limitation on activities of daily living. Thus, replacement with smaller and softer implants for increased comfort and improved appearance is not supported by the medical literature. The patient has also requested removal of the implants and replacement with smooth implants because of her concerns with breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Per the U.S. Food and Drug Administration (FDA), since BIA-ALCL has generally only been identified in patients with late onset of symptoms such as pain, lumps, swelling, or breast asymmetry, prophylactic breast implant removal in patients without signs or symptoms is not recommended. Current recommendations for treatment of textured breast implants include observation and follow-up. Prophylactic breast implant removal is not recommended in the absence of indicating signs or symptoms. Moreover, no functional issues with breast ptosis requiring mastectomy were documented in the medical records or photographs provided for review. Thus, the requested mastectomy revision and chest reconstruction (CPT codes 19371, 19316, 19380, and/or 19340) are 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; (2) to create a normal appearance, to the extent possible. This patient underwent fat grafting October 2019 with relief of blanching and vasospasm with activity. She reports that she still experiences pain and circulation issues when physically active for periods lasting several hours. Pain and circulation issues that allow intense activity and appear after several hours of intense physical activity do not constitute a functional limitation. Photographs do not demonstrate an abnormal physical appearance. The photographs show a normal contour within the range of normal for a transgender breast implant. The breast size does is not disproportionate or outside of the range of normal. The requested procedures will not provide a more than minimal improvement in the patients appearance. Given these findings, the requested mastectomy revision and chest reconstruction (CPT codes 19371, 19316, 19380, and/or 19340) are not reconstructive in nature for 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.