Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reconstruction (removal and replacement of breast implants). From the American Society of Plastic Surgeons (ASPS), breast deformities result from congenital anomalies, trauma, disease, or maldevelopment. Because breast deformities often result in abnormally asymmetrical breasts, surgery of the contralateral breast, as well as the affected breast, may be required to achieve symmetry. Breast reconstruction surgery to correct breast deformities, as well as surgery on the contralateral breast to achieve symmetry, are considered reconstructive surgery and, therefore, should be a covered benefit and reimbursed by third-party payers. The ASPS further noted that reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. As in this patients case, following mastectomy, the breasts are no longer normal. Procedures performed in order to correct the abnormal condition are considered reconstructive. This patient is documented to have previously undergone bilateral mastectomies followed by breast reconstruction with implants for fibrocystic disease. The treatment created a significant deformity as the entire breast volume was surgically removed. Thus, further procedures to correct deformities as a direct result of the initial treatment are supported as medically necessary and within the current standard of care. This patient presents with evidence of painful capsular contractures with breast deformity. This is an abnormal condition created as a direct result of previous breast reconstruction. Thus, the requested breast reconstruction (removal and replacement of breast implants) is medically necessary for treatment of this patients capsular contractures with breast deformity. Furthermore, the requested surgery is supported as reconstructive in nature. The patients condition constitutes an abnormal structure of the body caused by treatment of disease. The patient underwent previous mastectomy as a treatment of fibrocystic disease that removed breast tissue. The patient has painful capsular contractures with significant breast deformity. The requested surgery is expected to both improve function and create a normal appearance to the extent possible. The requested surgery should address painful capsular contractures and provide more than a minimal improvement in the patients appearance. Thus, the requested breast reconstruction (removal and replacement of breast implants) is medically necessary and reconstructive in nature for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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.