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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for left breast reconstruction and right breast augmentation for symmetry. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients status post left lumpectomy and are not reconstructive in nature. The concern addressed in this review is not a decrease in size of the left breast as a result of cancer surgery. In this patients case, the records document that the concern is a reported decrease in size of both breasts. The patient states that both breasts have gotten smaller since the cancer treatment. The patient states that the previous bra sized was a B cup, but now the bras do not fit even on the contralateral non-operated side. The patient requests authorization for a bilateral breast augmentation to correct bilateral volume loss with a larger implant on the left side. This is requested as a left breast reconstruction with a contralateral implant for symmetry but there is no report of volume loss on the left side that would not be addressed by staged fat grafting. The bilateral breast shrinkage in this patient is not a result of the left lumpectomy/partial mastectomy. According to the submitted medical records submitted for review, the requested breast augmentation is to correct bilateral volume loss noted after cancer treatment and not to reconstruct volume loss in the operated breast. The patient underwent acute surgical menopause as a consequence of a bilateral salpingo-oophorectomy and tamoxifen treatment. Researchers state that estrogen deficiency symptoms are established adverse effects of adjuvant endocrine therapy. Researchers find that it is well established that beast density declines with increasing age particularly around menopause and with tamoxifen use. Therefore, the requested left breast reconstruction and right breast augmentation for symmetry is not medically necessary. In this patients case, the medical documentation does not support that there is an abnormal structure of the body that would be addressed with left breast reconstruction and right breast augmentation for symmetry. Per the records, the patients breasts that have lost volume bilaterally are not considered abnormal structures of the body. Additionally, the requested services are not likely to improve function or create a normal appearance to the extent possible. There is no functional deficit reported in the medical documentation. There is no report that the loss of bilateral breast volume is a result of congenital defects, developmental abnormalities, trauma, infection, tumors or disease. The functional component and creation of a normal appearance is associated with the reconstructive surgery to the left breast with release of scar tethering and the fat grafting for a post-surgical/irradiation deformity and not with the left breast reconstruction and right breast augmentation for symmetry. There is insufficient evidence that a left breast reconstruction and right breast augmentation for symmetry would provide more than a minimal improvement. Therefore, the requested left breast reconstruction and right breast augmentation for symmetry is not medically necessary and is not reconstructive in nature.Final Result: The reviewer determined that the requested services at issue were not medically necessary and were 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.