Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.  The rules say that  Indications for specific surgical procedure      1. Breast reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is covered.     2. Removal or revision of a breast implant whether placed for reconstructive or cosmetic reasons, is considered medically necessary when it is removed for one of the following reasons:26         a. Mechanical complication of breast prosthesis; including rupture or failed implant, and/or implant extrusion.         b. Infection or inflammatory reaction due to a breast prosthesis; including infected breast implant, or rejection of breast implants.         c. Other complication of internal breast implant; including siliconoma, granuloma, interference with diagnosis of breast cancer, and/or painful capsular contracture with disfigurement.     3. Breast Reduction is the surgical reshaping of the breasts to reduce or lift enlarged or sagging breasts. Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit.      Macromastia (breast hypertrophy) is an increase in the volume and weight of breast tissue relative to the general body habitus. Breast hypertrophy may adversely affect other body systems: musculoskeletal, respiratory, and integumentary. Unilateral hypertrophy may result in symptoms following contralateral mastectomy.      Medical necessity for a breast reduction is limited to circumstances in which:         There are signs and/or symptoms resulting from the enlarged breasts (macromastia) that have not responded adequately to non-surgical interventions,         To improve or correct asymmetry following cancer surgery on one breast.          Note: either the involved breast or contralateral breast may be treated to achieve symmetry.         Note: For coverage indications for contralateral reconstruction of an unaffected breast following a medically necessary mastectomy, refer to the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, 140.2.      Non-surgical interventions preceding breast reduction should include as appropriate, but are not limited to, the following:         Determining the macromastia is not due to an active endocrine or metabolic process.         Determining the symptoms are refractory to appropriately fitted supporting garments, or following unilateral mastectomy, persistent with an appropriately fitted prosthesis or reconstruction therapy at the site of the absent breast.         Determining that dermatologic signs and/or symptoms are refractory to, or recurrent following, a completed course of medical management.      A medically reasonable and necessary breast reduction could be indicated in the presence of significantly enlarged breasts and the presence of at least one of the following signs and/or symptoms:         Back, neck or shoulder pain from macromastia and unrelieved by 6 months of:         - Conservative analgesia,         - Supportive measures (garment, etc.),         - Physical Therapy, or         Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity, or         Intertriginous maceration or infection of the inframammary skin refractory related to dermatologic measures.         Permanent shoulder grooving with skin irritation by supporting garment (bra strap).      The amount of breast tissue to be removed must be proportional to the body surface area (BSA) per the Schnur18 scale below. If the individual's body surface area and weight of breast tissue removed fall above the 22nd percentile, then the surgery is considered medically reasonable and necessary with the appropriate criteria. If only one breast meets the Schnur scale criteria; breast tissue may be removed from the other breast in order to achieve symmetry.  You can find this information in Medicare's Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L39051).  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.