Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve bilateral breast implant removal with capsulectomy (19371).You asked the Plan to pre-approve bilateral breast implant removal with capsulectomy. You say that the requested bilateral breast implant removal with capsulectomy is medically necessary.The Plan denied your request. The Plan says that the requested bilateral breast implant removal with capsulectomy is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 bilateral breast implant removal with capsulectomy. Our reviewer says that the requested bilateral breast implant removal with capsulectomy is medically necessary. Our physician reviewer found the enrollee is with a history of bilateral augmentation mammaplasty. Medical documentation from 2/20/2020 notes that the enrollee was seen on 11/12/2019 regarding problems with her 17-year-old breast implants. She has a history of fibromyalgia, vertigo, migraines, chest pain, TMJ, sinusitis, aging skin, weight gain and loss and no energy. She has been excluded for other underlying disease. She has daily pain and distress due to the breast implant status. Medical treatment has led to no relief of her symptoms. Examination notes that the breasts are asymmetric. They are hard, painful and abnormal in appearance. Plan is for breast implant removal. Based on the available documentation, the enrollee has significant pain and capsular contracture with distortion of her bilateral breast implants. She has been treated by multiple medical specialties without resolution or improvement. She has a functional impairment of pain, likely directly related to significant capsular contracture. As typical conservative management has failed, implant removal and capsulectomy would likely improve her impairment. Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Thus, as the enrollee has significant pain likely related to capsular contracture and typical conservative management has failed, bilateral implant removal/capsulectomy satisfies Medicare medically necessary criteria.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bilateral breast implant removal with capsulectomy have been met.Therefore, we decided that the Plan has to pre-approve bilateral breast implant removal with capsulectomy (19371). If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter