Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe bilateral removal of breast implants (19371) and the bilateral insertion of new breast implants (19325).You asked the Plan to pre-approvethe bilateral removal of breast implants (19371) andthe bilateral insertion of new breast implants (19325). You say that the bilateral removal of breast implants (19371) and the bilateral insertion of new breast implants (19325) are medically necessary.The Plan denied your request. The Plan says the bilateral removal of breast implants (19371) and the bilateral insertion of new breast implants (19325) are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the bilateral removal of breast implants (19371) and the bilateral insertion of new breast implants (19325). Our reviewer says that the bilateral removal of breast implants (19371) and the bilateral insertion of new breast implants (19325) are not medically necessary. Our physician reviewer found the enrollee is with a history of bilateral breast augmentation in 2002. She is noted to have had firm implants since her original surgery. She is documented to have a tender right breast mass. Plastic surgery documentation notes grade III capsular contractures of the breasts. Plastic Surgery documentation does not note evidence of pain or other functional impairment associated with her implants. Photographs provided are consistent with possible capsular contracture. Medical documentation, including MRI evaluation, do not note evidence of implant rupture. Based on the documentation provided, the enrollee has a typical complication regarding implant placement, capsular contracture. The only functional impairment documented is tenderness associated with a right breast mass. From Medicare, Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illnessor injury or to improve the functioning of a malformed body member. There is no functional impairment documented that would be addressed with capsulectomy and implant exchange (CPT 19371 and 19325). In addition, as there is insufficient evidence that the original implants were 
placed for medically necessary reasons, correction of this complication should not be considered medically necessary as well. If the enrollee had significant pain associated with the capsular contracture, then consideration could be given for implant removal as a medical necessary procedure, but not implant replacement.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the bilateral removal ofbreast implants (19371) and the bilateral insertion of new breast implants (19325) have not been met.Therefore, we decided that the Plan does not have to pre-approvethe bilateral removal of breast implants (19371) and the bilateral insertion of new breast implants (19325)