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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 cosmetic surgery and related services, except as required for the prompt repair of accidental 
injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 
CFR Section 411.15(h). 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
A. The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The 
rules say there are 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:
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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. 
You can find this information in Medicares Local Coverage Indication  Cosmetic and Reconstructive Surgery 
(L39051).