Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast pain
Treatment:  Breast Surgery (Mastopexy - CPT 19316-50); Peri-Implant Capsulectomy (CPT 19371-50)
The insurer denied the  Breast Surgery (Mastopexy - CPT 19316-50); Peri-Implant Capsulectomy (CPT 19371-50)
The denial is upheld

This female patient underwent a breast augmentation approximately seven years ago. She needed a revision of her surgery when her right breast implant ruptured. She underwent a bilateral removal of her breast implants and replacement. She was initially an A-cup and the implants brought her up to a C-cup. For the last few years, she has had a significant amount of pain in her breasts due to her implants and periprosthetic scarring, the right breast has more pain than the left breast. This pain inhibits her activities of daily living making it difficult for her to exercise, lift boxes, and put on clothing. She has systemic symptoms as well including chronic fatigue, joint pain, hair loss, vision changes, and issues with her memory. She is also concerned about the health implications of implants, specifically the risk of anaplastic large cell lymphoma (ALCL). 

On exam her implants are heavy, and asymmetrical causing significant back, neck, and shoulder pain. She also has hard, palpable, visible, baker IV(intravenous) capsular contracture bilaterally. Due to the size and location of the implants, they cause functional impairment and difficulty performing activities of daily living. The patient's surgeon recommends removal of her bilateral breast implants, capsulectomy, and reconstructive mastopexy. Due to the change in the breasts over the years of having the implants, the patient will need a reconstructive mastopexy given the breast shape, significant ptosis, and skin quality. She will also likely need a pectoralis muscle repair due to damage from the implants as well as a capsulectomy due to baker IV capsular contracture which, once removed, should improve her ability to perform activities of daily living.

No, the proposed treatment is not medically necessary.
The procedures are cosmetic.  The patient has periprosthetic capsular contracture, which is a known complication of breast implants.  A study by Dancey et al found a 26.9% incidence of capsular contracture following breast augmentation surgery.  

The original procedure was for cosmetic purposes.  Capsular contractures typically cause discomfort and pressure in the breast, but have no long-term health risks if untreated.  When implants are placed for reconstructive purposes, treatment of these complications should be a covered service. However, in this case, the initial procedure of breast augmentation was strictly a cosmetic procedure.  

Using the American Society of Plastic Surgeons (ASPS) position paper on reoperation for implants placed for cosmetic augmentation, the medically necessary conditions for reoperation are broken or failed implant, infection, implant extrusion, siliconoma or granuloma, interference with the diagnosis or treatment of breast cancer.  The American Society of Plastic Surgeon's position paper goes on to say that insurance carriers "respond thoughtfully and with compassion on an individual basis" for several other conditions including "mastodynia (painful breasts) and medically significant capsular contracture (capsular contracture that produces pain, disfigurement and/or interferes with mammography)." 

Capsular contracture is a benign condition. Although contractures can be painful, they do not pose a health risk or danger.  Surgery will make the patient more comfortable and will improve the appearance of her breasts, but it is not necessary to prevent a disease or illness or to treat a functional problem.

Yes, the health plan act reasonably, with sound medical judgment and in the best interest of the patient.
These are cosmetic procedures to improve appearance.  They are not medically necessary.