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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast reconstruction surgery. Genova and Garza reported that, Breast fat necrosis is nonviable adipose cells from injured or ischemic breast tissue that is replaced with scar tissue and presents as a palpable nodule. Breast fat necrosis has various etiologies and implications; therefore, a careful patient history is imperative to properly evaluate the patient. The most common etiology of fat necrosis is recent breast surgery. In a review of fat grafting to the breast, researchers noted that, Small volume fat grafting is no longer controversial and has become common practice for step-off deformities and contour irregularities. On review of the available documentation, this patient is status post bilateral breast reduction, not breast reconstruction. The patients diagnoses do not include deformity or disproportion of reconstructed breast, which may be an indication for the requested surgical procedure. In addition, the photographs available in the records were taken shortly after the patients breast reduction surgery. Photographs demonstrating the patients current physical condition were not included for review. Furthermore, there is a lack of documentation of any functional issues present that are planned to be corrected by the proposed surgical fat grafting. The patient complains of hyperpigmentation of her breasts and depression of the nipple areolar complexes. Hyperpigmentation of the skin of the breast will not be affected by the proposed surgery and does not support an indication for the procedure. Based on the medical information received for review, the requested breast reconstruction surgery is not medically necessary for treatment of this patient. The California Reconstructive Surgery Statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. This patient is reported to have depressions in the area of her areolae bilaterally from her previous breast reduction surgery, which constitutes an abnormal structure of the body caused by trauma from surgery. However, the records fail to document any functional issues that would be corrected by the proposed fat grafting, or that the requested procedure would create a more than minimal improvement in the patients appearance. The provider indicates that the fat grafting procedure has been recommended to create a normal appearance to the extent possible. The records do not include photographs accurately depicting the extent of the patients current clinical problem. Overall, there is a lack of evidence that the requested breast reconstruction surgery has been recommended to improve function or provide a more than minimal improvement in the patients appearance. Based on the medical information received for review, the requested breast reconstruction surgery is not reconstructive in nature for treatment of this patient. All told, the requested breast reconstruction surgery is not medically necessary and not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not 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.