Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approve the implant removal and replacement (19328 and 19340). We decided that the Plan does not have to pre-approve the right mastopexy (19316).  
 
You asked the Plan to pre-approve the implant removal and replacement (19328 and 19340). You say that this should be considered a medical procedure as prior surgeries to correct your initial reconstruction have left you with asymmetry and some pain. The Plan says that this surgery is requested solely to improve physical appearance and cannot be covered. 
 
We decided that the Plan has to pre-approve the implant removal and replacement (19328 and 19340).  
 
The Plan follows Medicare rules. Medicare rules say that coverage is allowed for medically necessary reconstructive surgery.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the implant removal and replacement (19328 and 19340). Our reviewer says that the requested breast reconstruction is considered medically reasonable and necessary and is not cosmetic in nature. However, a right mastopexy is not appropriate as this has already been provided in the past. Our physician reviewer found Based on the documentation provided, the patient has evidence of significant asymmetry in the setting of previous breast reconstruction for a congenital deformity. Thus, this should be considered part of breast reconstruction to approximate a relatively normal condition. Currently, the patient has evidence of a significant asymmetry of her previous reconstructions. Thus, procedures to reasonably correct this should be considered reconstruction revision to approximate a more normal appearance. This is not cosmetic surgery, but reconstructive surgery. However, the codes chosen are not consistent with the planned procedures. As the patient has already undergone mastopexy on this side, there is a more appropriate code to describe reconstruction (19380) rather than mastopexy (19316). As the planned procedures are consistent with breast reconstruction for an initial congenital deformity, they are necessary for the treatment of this condition. Thus, they satisfy Medicare medically necessary criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the implant removal and replacement (19328 and 19340) have been met. Therefore, we decided that the Plan has to pre-approve the implant removal and replacement (19328 and 19340).  
 
We also decided that the Plan does not have to pre-approve the right mastopexy (19316). 
 
The Plan follows Medicare rules. Medicare rules say that payment may only be made for services that are considered medically necessary. 
 
As noted above, our reviewer finds that the use of the code 19316 is not appropriate for a reconstruction in this case as there is already a history of mastopexy on this side. Although reconstruction is considered reasonable and necessary, it cannot be approved under this particular code. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the right mastopexy (19316) have not been met. Therefore, we decided that the Plan does not have to pre-approve the right mastopexy (19316). 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.