Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congenital Malformation
Treatment: Breast Reconstruction
The insurer denied: Breast Reconstruction
The denial is overturned.

The patient is a young adult female. She presented to the plastic surgery provider with chief complaint of breast asymmetry, specifically, right breast hypoplasia (congenital deformity). Her current bra size on left is B and she uses bra inserts to fill out the right side.

The patient never had development on right breast, which causes significant psychological distress for the patient. She sees a therapist, who is supportive of her seeking reconstructive surgery. Menarche was at 15. She feels left breast size may have slightly increased in the past 6 months, because she has to use more padding on the right to match their size.

The patient is a dancer, and breast asymmetry has caused her issues with fitting into costumes appropriately and highlights her body image issues. Her past history is negative for breast cancer or other breast pathology. Her right breast is noted to be Tanner stage 3.

The plan that was recommended for the patient included right tissue expander placement (could be anytime) with staged exchange for permanent implant and left sided balancing mastopexy +(plus)/-(minus) implant placement to optimize shape. This would allow the process to start while the left breast growth stabilizes.

The Breast Reconstruction is medically necessary.

Per the denial letter: "...the health plan decided to deny this service because the service is not medically necessary. You asked for breast reconstruction using tissue expander (surgery used to correct a defect in the appearance of your breast) because of a congenital malformation of the breast. To approve this service the following criteria must be met: Per InterQual 2021 Procedure Breast Reconstruction, this procedure is considered medically necessary when the following criteria are met: a congenital disorder or condition causing severe breast disfigurement is present, breast is hypoplastic or absent or there is congenital absence or hypoplasia of pectoralis major muscle. These criteria are not met because there is no documentation of congenital disorder or condition causing severe breast disfigurement, congenital absence or hypoplasia or pectoralis major muscle or breast hypoplastic or absent."

The denial is in error. According to the plastic surgery note, the patient has limited right breast development and breast asymmetry. Per the note from her PCP (primary care provider: "[The patient] is under my medical care. I have been following her medically for her eating disorder. As part of the medical and psychiatric management of this, other contributing factors to her clinical picture have arisen, including her congenital breast deformity. This part of her physical body has had a significantly negative impact on her psychological health; worsening her mood symptoms which have had downstream negative effects on her ability to go to school and overall quality of life. It has also made treatment of her psychiatric illnesses more difficult."

This patient has breast asymmetry and breast hypoplasia and has a functional deficit as documented in the PCP (primary care provider) note. The patient therefore meets medical necessity for the requested health service.