Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Breast Ductal Carcinoma in situ

Treatment: Nerve Repair with Allograft (tissue graft from a donor) or Synthetic (produced by chemicals), Nipple-Sparing; billing code 64910

The insurer denied the nerve repair with allograft (tissue graft from a donor) or synthetic (produced by chemicals), nipple-sparing; billing code 64910.

The denial was upheld.

This patient is a female patient who was diagnosed with ductal carcinoma in situ in one breast by Mammogram, MRI and biopsy. Bilateral mastectomies with immediate breast reconstruction, axillary node dissection, nipple sparring mastectomies with immediate sensory nerve reconstruction with allograft is being considered. The patient has a strong family history of breast cancer with mother diagnosed at a young age and she is BRCA positive.

"Nipple-sparing mastectomy (NSM) is considered an oncologically safe option for select patients. As many patients are candidates for nipple-sparing or skin-sparing mastectomy (SSM), reliable patient-reported outcome data are crucial for decision-making. The objective of this study was to determine whether patient satisfaction and/or health-related quality of life (HRQOL) were improved by preservation of the nipple with NSM compared to SSM and nipple reconstruction...NSM is associated with higher psychosocial and sexual well-being compared to SSM and nipple reconstruction. Preoperative discussion of such HRQOL outcomes with patients may facilitate informed decision-making and realistic postoperative expectations." (Wei, C.H., et al., 2015).

"Skin-sparing (SSM) and nipple-sparing (NSM) mastectomies are relatively new conservative surgical approaches to breast cancer. In SSM most of the breast skin is conserved to create a pocket that facilitates immediate breast reconstruction with implant or autologous graft to achieve a quality cosmetic outcome. NSM is closely similar except that the nipple-areola complex (NAC) is also conserved. Meta-analyses indicate that outcomes for SSM and NSM do not differ from those for non-conservative mastectomies. Recurrence rates in the NAC after NSM are acceptably low (0-3.7%). Other studies indicate that NSM is associated with high patient satisfaction and good psychological adjustment......For breast cancer patients requiring mastectomy, NSM should be the option of choice." (Galimberti, V., et al, 2017).

"Patients undergoing SSM and NSM have considerable loss in skin and NAC sensation following surgery. Satisfaction and QOL did not differ between groups. J. Surg. Oncol. 2016;114:11-16.  2016 Wiley Periodicals, Inc." (Dossett, L.A., et al, 2016).       

Although nipple sensation is the goal to restore a breast, the studies are limited and the procedure is considered unproven. Patients without this procedure regain sensation in 47% of the cases. 

While the patient is a good candidate for nerve reconstruction with allograft, she is young, a nipple sparring mastectomy is planned and she desires to preserve sensation on the nipple, it is not needed in all patients and not performing this procedure on this patient will still give her a pleasing result. Patients without this procedure regain some if not all the sensation to the nipple. The nerve reconstruction to enhance sensation to the nipple areola is not needed since many patients recover sensation on their own after this surgery and the procedure has not been tested widely and it is not performed as the standard of care in all of these surgeries.

Based on the above, allograft (tissue graft from a donor) or synthetic (produced by chemicals), nipple-sparing; billing code 64910 is upheld. This procedure is not likely to be more beneficial than any other standard treatments or procedures.