Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast mass
Treatment is removal of a mass in the breast as an outpatient
The insurer denied coverage for removal of a mass in the breast as an outpatient
The denial is overturned.

This is the case of a female with a medical history of breast masses. She had bilateral breast excisional biopsies for a breast mass in an outpatient hospital setting. As per the office visit the patient was seen for consultation. As noted, the patient had a right axillary ultrasound which showed a 1.8 cm (centimeter) lobulated mass in vascularity, no fatty hilum, and separate from the skin, and an abnormal lymph node with the recommendation of a repeat sonograph in 3-4 weeks. She had right axillary ultrasound with the finding of a 2.2 cm mass with biopsy recommended. The patient had a right axillary mass core biopsy which was found to be fibroepithelial lesion with background breast parenchyma being predominantly fatty. The comment was distinction between a fibroadenoma and a phyllodes tumor is best made on the entire lesion. The provider also noted that flow cytometry did not demonstrate viable hematopoietic cells (as the lesion was not a lymph node). On a visit with the provider a mass was noted in the right axilla not increasing in size. The patient was G (gravida) 0 P (para) 0. There was a 1 cm mass in the left breast and a 2 cm mass in the right breast. The plan was bilateral breast excisional biopsies.

Based upon the information provided, coverage for removal of a mass in the breast as an outpatient should be covered. The insurer is incorrect in denying surgery and is incorrect in stating that the criteria for surgery were not met at the facility where it was done. An ambulatory surgery center, also known as an ASC, is a healthcare facility where surgical procedures and other procedures that do not require an overnight hospital stay take place. ASCs are either freestanding medical facilities or part of larger healthcare organizations. 

According to MCG (Milliman Care Guidelines) Health General Recovery Guidelines 26th edition General Surgery or Procedure GRG: SG-GS (ISC GRG), Operative Status Criteria is ambulatory for many procedures. Examples include: Endoscopic procedures; Embolization procedures; Most biopsy procedures; Many elective operations; including Stoma  repair, Fistula repair, Lymph node surgery; Hernia repairs in the absence of ALL of the following: Emergency procedure (e.g. strangulated hernia), Severe co morbid disease (e.g., severe infection), Complex approach (e.g., morbid obesity, large chronic incarceration); Hemorrhoid or rectal surgery; Most breast procedures; Percutaneous and dilation procedures; Liver biopsy. In this case the patient had the biopsy done at an ambulatory surgical center which is the outpatient ambulatory center for the hospital. It was not done at the hospital itself. In fact, the patient was originally scheduled to have it done at the hospital but moved to this outpatient facility after being notified by the insurer that the patient needed to have it done at an ambulatory outpatient surgical center. Thus, the surgery was done at the ambulatory surgical center. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the removal of a mass in the breast as an outpatient is overturned. Medical Necessity is substantiated.