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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast augmentation revision/reduction surgery with modifier 50, performed treatment of the enrollee, who reported lower back pain and pain between her ribs. Findings: The physician reviewer found that the patient had undergone revision of her previous augmentation with placement of smaller implants and a mastopexy. Although the patient is noted to have chronic back pain possibly related to her previous breast augmentation, the indications for the procedures were that the patient desired smaller implants and that she had severe rippling.  The plastic surgery documentation did not describe a clear functional deficit related to the size of the original implants.  Instead, the documentation from notes aesthetic concerns as the patient reported dissatisfaction with the size of her original implants and reported that there was rippling. These concerns can be considered typical risks associated with augmentation mammaplasty.  In addition, the implants that were placed were only 80 cc smaller than her original implants.  This reduction in volume would not be expected to provide significant relief in chronic back pain.  Based on the entirety of the medical records, the patient had well documented complications associated with her original breast augmentation.  However, despite the patients chronic back pain, the plastic surgery documentation and operative notes are more consistent with cosmetic interventions and not treatment of functional compromise.  Additionally, the patients condition did not constitute an abnormal structure of the body based on the medical documentation. Although the patient has evidence of rippling of her implants and that the implant size may have been undesirable, the breasts were not abnormal body structures. Moreover, reducing the size of the implants by 80 cc would not likely have any effect on the patients functional impairment. The original breast augmentation was performed for cosmetic reasons and the patients medical condition was related to common complications from the previous breast augmentation. Generally, intervention related to a cosmetic procedure should also be cosmetic. With regards to complications after breast augmentation, Handel and colleagues note the following, It has become increasingly apparent in recent years that breast implant recipients experience a significant incidence of complications and a relatively high rate of reoperation. In large-scale follow-up studies conducted by manufacturers, it was reported that by the end of 5 years, women undergoing augmentation with saline-filled implants had a 10 percent rate of significant (Baker grade 3 or 4) contracture From Marquis and colleagues, they note that, Capsular contracture is the most common and severe complication associated with silicone breast implants. In addition, replacing the implants with slightly smaller implants, as documented, would not likely produce a functional improvement. All told, the breast augmentation revision/reduction surgery was not medically necessary and was not reconstructive in nature.Final Result: The reviewer determined that the services at issue were not medically necessary or 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.