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

Nature of Statutory Criteria/Case Summary: The patient is a 62-year-old female with a history of intraductal carcinoma in situ of the left breast.Findings:  The physician reviewer found that the patient presented for bilateral nipple sparing mastectomies, left axillary sentinel lymph node biopsy, and AlloDerm assisted immediate bilateral breast reconstruction with silicone implants. Later , the records noted that bilateral breast implants were in place, with no signs of infection, hematoma, seroma, or ischemia. Then the records noted that the patient would like larger implants to be placed. In an application for independent medical review , the patient reported asymmetry of the breasts and a large space between the breasts. The patient has requested authorization and coverage for breast reconstruction revision surgery ( open periprosthetic capsulotomy breast,suction assisted lipectomy trunk, tissue graft other, mastopexy) and implant materials and procedure (immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction, and implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement (i.e., breast, trunk)). The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this patients case is whether breast reconstruction revision surgery ( open periprosthetic capsulotomy breast, suction assisted lipectomy trunk, tissue graft other, mastopexy) and implant materials and procedure (immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction, and implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement (i.e., breast, trunk)) are medically necessary for the treatment of the patients medical condition. Additionally, 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 defects, developmental abnormalities, trauma, infection, tumors or disease? Are the requested breast reconstruction revision surgery and implant materials performed to either improve function or create a normal appearance to the extent possible? Does the surgery provide more than a minimal improvement in the appearance of the patient? If the above factors are met, the services must be provided under the expanded concept of medically necessary reconstructive surgery defined in California law. Prepectoral direct-to-implant breast reconstruction provides the potential benefits of a single-stage operation, elimination of dynamic deformity, enhanced aesthetic outcomes, and increased patient satisfaction (Antony and Robinson).  In this patients case, the records do not document functional disability. There is no documentation of complications related to the breast implants. The clinical notes did not document capsular contracture or implant malposition.  The medical records do not support the medical necessity of the requested services in this clinical setting. Therefore, breast reconstruction revision surgery (open periprosthetic capsulotomy breast, suction assisted lipectomy trunk, tissue graft other mastopexy) and implant materials and procedure ( immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction, and implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement (i.e., breast, trunk) are not medically necessary for the treatment of this patient. In this case, the patients condition does not constitute an abnormal structure of the body. The photographs are consistent with the expected outcome for reconstruction. Breast reconstruction surgery is not likely to improve function or create a normal appearance to the extent possible. There is no indication that the patient has diminished function due to her breast implants. According to the medical records, the patient requested a change in the size of her breast implants. The requested services are not likely to provide more than a minimal improvement in the appearance of the patient. Therefore, the requested breast reconstruction revision surgery (open periprosthetic capsulotomy breast, suction assisted lipectomy trunk, tissue graft other, mastopexy) and implant materials and procedure  immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction, and implantation of biologic implant (e.g, acellular dermal matrix) for soft tissue reinforcement (i.e., breast, trunk) are not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. 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.