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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for right-sided mastopexy and bilateral implant removal and replacement. Findings:  The physician reviewer found that  Ribeiro and colleagues noted that, The term tuberous breast is used to define a syndrome consisting of a hypoplastic alteration of the breast, where there is a base of insufficient diameter for the glandular content, accompanied by a pseudo-herniation of the same through the areola, with a deficit of skin wrap and a poorly positioned inframammary crease, which is usually located above the desired location; thus, giving the tubular appearance that identifies it. The authors commented that the changes of a womans breasts should be harmonious in appearance or they can otherwise cause unwanted psychological conduct with falling levels of self-esteem and stress of neurotic or bipolar disorders that could generate a progressive and destructive dissatisfaction with a womans personal development. This patient reportedly underwent prior correction of tuberous breast deformity. However, on review of the patients records and available photographs, there is a lack of documentation of any residual tuberous breast deformity. The patient gained substantial weight. She has a breast asymmetry of approximately 100 grams and mild ptosis on the right side. The patient indicated that she experiences symptoms including shooting pain, particularly in her left breast. Overall, there is a lack of evidence of significant or severe capsular contracture. The patients appearance is within the wide range of normal for a female chest. In addition, the provider did not chart the presence of any significant functional issues related to the patients breasts. For these reasons, the requested right-sided mastopexy and bilateral implant removal and replacement are not medically necessary for 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; or (2) to create a normal appearance, to the extent possible. This patient underwent prior correction of tuberous breast deformity. On review of the available documentation and photographs, no residual deformity is indicated. The patient is obese, has breast asymmetry of approximately 100 grams, and mild ptosis on the right side. The patients breasts are within the wide range of normal for a female. Moreover, there is a lack of documentation of significant capsular contracture or of any functional deficiencies that would be addressed by a right-sided mastopexy, bilateral implant removal, and/or implant replacement. Given these findings, the requested right-sided mastopexy and bilateral implant removal and replacement are not reconstructive in nature for this patient. All told, the requested right-sided mastopexy and bilateral implant removal and replacement are not medically necessary and not reconstructive in nature for treatment of 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.