Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a bilateral breast implant removal and total capsulectomy procedure.Kimura and Cohen (2017) report that chronic active EpsteinBarr virus (CAEBV) is a rare disorder in which persons are unable to control infection with the virus. They state that primary infection of adolescents and young adults often results in infectious mononucleosis with fever, lymphadenopathy, and sore throat. They state that chronic active EpsteinBarr virus (CAEBV) has been reported in adults and that it may be indolent with episodic fever, lymphadenopathy, and viral hepatitis followed by periods that are nearly asymptomatic.Cohen Tervaert and colleagues state that autoimmune/inflammatory syndrome by adjuvants (ASIA), allergies, autoimmune diseases, immune deficiencies and lymphomas occur in patients with silicone breast implants. They state that there is a need for adequately adjusted epidemiological studies to ascertain the frequency of these diseases. On the other hand, Balk and colleagues state that the evidence remains inconclusive about any association between silicone gel implants and long-term health outcomes. Chao and colleagues state that breast implant surgery is one of the most commonly performed procedures in the field of plastic surgery. They note that while silicone implants are now routinely used in breast surgery, they have previously been the subject of controversy. This was particularly true in the U.S., where there was a moratorium on their use from 1992 to 2006. Following subsequent scientific validation of their safety, silicone implants have re-gained widespread acceptance for clinical use. Chao and colleagues state that overall, silicone breast implants are associated with a high degree of patient satisfaction and low rates of complications. They state that further independent research is necessary to better establish long-term outcomes.In this case, the patient was noted to have chronic active EpsteinBarr virus (CAEBV) syndrome, which causes fatigue and lymphadenopathy. The patient reported that she had an abnormality in her white blood cell count, but the white cell count and differential that are included in the submitted medical records were within normal limits. The patient reported that she had a large tumor/suspicious mass in her neck, but the patients hematologist noted only tiny lymph nodes. While the patient reported a concern about BIA-ALCL lymphoma because of her implants, this condition is essentially limited to textured implants, and there was no report that she had textured implants. The patient suffered from generalized complaints in which association with the presence of silicone gel implants cannot be confirmed. They were systemic complaints in which causation from silicone gel implants is speculative and unsupported. Therefore, the bilateral breast implant removal and total capsulectomy procedure at issue was not medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for 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.