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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a right breast implant. There is a general consensus that symptomatic and/or extracapsular implant rupture warrants explanation with or without implant replacement. Explanation is recommended when the signs of silicone migration such as pain, lumps, granulomas, and increasing fibrosis are present. Hillard and colleagues state, The current recommended surgical management of diagnosed or symptomatic ruptured silicone breast implants is removal, generally including a complete capsulectomy. When the rupture is intra-capsular, i.e., free silicone is contained with the surrounding fibrous capsule; explantation involves removal of the implant and any free silicone, capsulectomy and replacement of the implant if the patient wishes. Extra-capsular rupture, with free silicone in the breast tissue, is managed similarly with the added resection of any visible or palpable granulomas present in the breast parenchyma. Koutroulis and Tsarouhas state, Extracapsular rupture means that the silicone gel has extended past the capsule and into the surrounding soft tissues. This may result in a palpable or tender mass on exam secondary to local inflammation. Because of the local inflammatory reaction to silicone gel, many would advocate for removal or replacement of known ruptured silicone breast implants. However, in patients who are asymptomatic, replacement is recommended but considered elective. In this case, the patient sustained a traumatic rupture of her silicone gel breast prosthesis that was placed for cosmetic purposes and reports pain as a result. While removal of the ruptured prosthesis and associated silicone gel is medically indicated,  replacement of the cosmetic breast implant is elective and is not medically indicated. Therefore, a right breast implant is not medically necessary for the 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. However, a cosmetic breast implant does not constitute a structure of the body. The presence of a cosmetic implant, in the absence of adjacent native tissue structural pathology, does not constitute an abnormal structure. The requested procedure is not being performed to improve function or create a more than minimal improvement in the patients appearance. For these reasons, a right breast implant is not reconstructive in nature for this patient. Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition and is not reconstructive in nature. 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.