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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for breast implant removal surgery (CPT 19371-RT, 19371-LT, 19328-RT, and 19328-LT) performed by Dr. Lisa Cassileth on 11/02/20.At issue is whether breast implant removal surgery (CPT 19371-RT, 19371-LT, 19328-RT, and 19328-LT) performed by Dr. Lisa Cassileth on 11/02/20 was medically necessary for treatment of the patients medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?Florin and Haiavy state, Capsular contracture is a troublesome complication of breast implants which may require revision surgery. Capsular contracture initially presents with firmness of the breast and can progress to pain and distortion of the breast shape and volume. When an implant is placed, a fibrous capsule forms around it. In a normal breast, the capsule is thin and soft, with no effect on the appearance of the breast. In a contracted breast, the capsule becomes thick and hard, and shrinks in a way which alters the contour of the breast and the position of the implant. Additionally, Wan and Rohrich state that clinically significant capsular contracture presents as a firm, tight-appearing breast that may progress to breast distortion and pain. The Baker classification describes four grades of capsular contracture, with grade I being a normal, soft breast; grade II being a minimally firm breast; grade III being a moderately firm breast with some visible deformity; and IV being a painful, hard, distorted breast. Grade III and IV contractures typically require surgical management. Moreover, Bachour and colleagues indicate, Capsular contracture is the most frequent complication after breast augmentation or reconstruction with breast implants. It is the primary reason for reoperation and has high recurrence rates. Hardening, distortion of the breast, and pain are symptoms of capsular contracture. The degree of contracture is clinically graded by the grading system according to Baker. The prevalence of capsular contracture varies between 5% and 19% for breast augmentation.In this case, the patient underwent cosmetic breast augmentation approximately 25 years ago and the implants were replaced in 2009. She had large implants and wanted them replaced with smaller implants. She developed a Grade IV capsular contracture on the left side with hardness and distortion, while the right side remained soft. A full capsulectomy was performed on the left side.  The implant was replaced with a smaller size. The right side underwent only a partial capsulectomy to allow downsizing of the implant.  Acellular dermal matrix was placed bilaterally to reduce the risk of capsular contracture. Capsulectomy was medically necessary on the left breast because of the Grade IV capsule. Capsulectomy was not medically necessary on the right breast because there was no report of a Grade IV capsule. Replacement and downsizing of the breast implants which were implanted for cosmetic purposes was cosmetic and not medically necessary. Therefore, only the left breast implant capsular removal surgery (CPT 19371-LT) performed by Dr. Lisa Cassileth on 11/2/20 was medically necessary for this patients medical condition. Based on the records, CPT codes 19371-RT, 19328-RT, and 19328-LT performed by Dr. Lisa Cassileth on 11/02/20 were 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. For the periprosthetic capsulectomy of the right breast (CPT 19371-RT), the right breast capsule was not an abnormal structure of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. Therefore, the right partial capsulectomy was not reconstructive in nature.The removal of the intact right mammary implant (CPT 19328-RT) was not for treatment of an abnormal structure of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. Therefore, the removal of the intact right mammary implant was not reconstructive in nature.For the removal of the left mammary implant (CPT 19328-LT), The American Society of Plastic Surgeons states that the use of CPT 19371 periprosthetic capsulectomy breast includes removal of all intra-capsular contents. While CPT 19371-LT periprosthetic capsulectomy is allowable as medically necessary, 19328-LT removal of the intact mammary implant is included in CPT 19371-LT. Separate billing for 19328-LT would constitute unbundling. The removal of the intact left mammary implant was not medically necessary as a separately billable service.Final Result: The reviewer determined that some of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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.