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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for mastopexy. Researchers discussed a patient who sustained bilateral breast implant rupture following elective electrical cardioversion for atrial fibrillation. The researchers reported that capsular formation with dense muscular attachments is a known complication with breast implants, while breast implant rupture is uncommon and may be associated with significant health and cosmetic consequences. Researchers noted that that surgical intervention for diagnosed or symptomatic ruptured silicone breast implants is removal, generally including a complete capsulectomy. In addition, for intracapsular rupture, explantation involves removal of the implant and any free silicone, capsulectomy and replacement of the implant if the patient wishes. Researchers state that, mastopexy and mastopexy-augmentation are aesthetic breast surgeries that seek to create youthful, beautiful appearing breasts. This patient sustained intracapsular breast implant rupture with seroma following external cardioversion. Removal of the implant, capsule, and silicone infiltrated tissue excision was appropriate. However, the patient elected to undergo mastopexy at the same surgical procedure to correct breast ptosis and to improve the shape of the breast after implant explantation. Mastopexy to correct breast ptosis and to improve the shape of the breast after implant explantation is not performed to address a functional issue related to the implant. A mastopexy would improve the patients appearance, but would not address the patients pain. Therefore, the mastopexy procedure was 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, tumor, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. Silicone gel-filled implants are silicone shells filled with a plastic silicone gel designed to give the appearance of larger breasts when introduced into the body during a surgical procedure. The implants are not incorporated into the body but remain separate. Silicone gel-filled implants are not structures of the body. The presence of a cosmetic implant, in the absence of adjacent native tissue structural pathology, does not constitute an abnormal structure. Thus, the ruptured right breast implant does not constitute an abnormal structure of the body. In addition, the mastopexy was not performed to improve function, as the records do not document a functional issue related to the implant. Moreover, the mastopexy would not have provided a more than minimal improvement in the patients appearance. All told, the mastopexy procedure was not reconstructive in nature for treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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.