Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast surgery. Researchers noted that capsular contracture is a known complication of breast implants that presents with firmness of the breast and can progress to pain and distortion of the breast shape and volume. Researchers stated that, medical treatment of symptomatic cases seems to be ineffective and surgical therapy is associated with a significant rate of recurrence. The researchers discussed the Baker classification system, which is based on clinical findings. Per the authors, Class III and IV are clinically significant and symptomatic, with III describing moderate contracture with some firmness felt by the patient and IV describing severe contracture which is obvious from observation and symptomatic in the patient. The records provided for review document that this patient is status post bilateral saline breast augmentation. She reports that she has developed hardening of the right breast over the past several months. Physical examination reports a considerable degree of firmness around the right breast implant with a moderate amount of superior malposition and a mild capsular contracture on the left. Photographs show a grade III contracture on the right and a grade II contracture on the left. The left breast has a normal appearance with a mild contracture grade II. There is no complaint of pain documented. The right breast shows a grade III contracture with a considerable degree of firmness and a moderate amount of superior malposition. The patient complains of pain and increasing discomfort. However, grade III contracture is a known complication of breast augmentation surgery and does not constitute a functional disability. The bilateral implants are intact and do not require replacement. Given these findings, the requested breast surgery is not medically necessary for this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. Breast implants are not abnormal structures of the body. The records note that the right breast capsule is causing the patient increasing discomfort. There is no report of a functional impairment related to the patients breast implants. Moreover, the appearance is within the range of normal for a female body with breast implants. Thus, the requested breast surgery would not provide a more than minimal improvement in this patients appearance. All told, the requested breast surgery is not reconstructive in nature for this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.