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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for mastectomy coupled with nerve grafts and sensory re-innervation and breast reconstruction to include implants. The enrollee tested positive for the BRCA1 gene mutation. She has a family history of breast cancer in her mother. She has been doing surveillance with breast exams, mammograms, and magnetic resonance imaging (MRI) for years. She underwent a risk-reducing bilateral salpingo-oophorectomy (BSO), as well as removal of a uterine polyp. During the procedure, there were findings consistent with bilateral ovarian cancer. She was referred to a gynecologic oncologist and began chemotherapy. She underwent an abdominal hysterectomy and omentectomy. She is now requesting coverage for a mastectomy, coupled with nerve grafts and sensory re-innervation, and breast reconstruction to include implants. The enrollee states the procedure she is requesting is superior to the one available through her health plan, which results in cessation of breast sensation and causes numbness to the upper body. This outcome is not associated with the nerve-graft procedure. The surgeon indicates that when done through a team approach at the time of mastectomy, carefully combining nerve preservation and grafting, women have the opportunity to maintain their breast and nipple sensation after nipple-sparing mastectomy and immediate reconstruction; thus greatly reducing the potential morbidity of the procedure. The enrollees risk-reducing surgery includes a bilateral mastectomy. The medical literature for invasive breast cancer list appropriate procedures for reconstruction, which include autologous tissue transplantation (pedicled TRAM flap, microsurgical flaps from various areas of the body), latissimus dorsi flaps or breast implants; +/- tissue expanders. There is no Level I evidence that indicates nerve restoration is appropriate to maintain sensation. This surgery has not evolved to the point where it is considered part of the standard of care. An analysis of  studies in the peer-reviewed literature regarding breast neurotization (nerve transfer) indicated variability in the methods used in the studies and inconsistent measurable outcomes across studies. The data demonstrates postoperative sensation returns spontaneously and unpredictably.  Significant study design discrepancies exist, making it difficult to combine data and assess results. To effectively study breast sensation and this procedure, future investigation will depend on standardizing the way in which breast sensation is measured.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in plastic and reconstructive 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 similar medical condition.