Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast implant removal surgery and breast lift surgery. There is a lack of evidence in current medical literature that silicone gel or saline breast implants are related to autoimmune systemic symptoms.Researchers noted that traditionally, capsular contracture is treated surgically, although it is important to note that treatment is only indicated in grades III and IV capsular contracture. Researchers stated that clinically significant capsular contracture presents as a firm, tight-appearing breast that may progress to breast distortion and pain. The Baker classification describes four grades of capsular contracture, with grade I being a normal, soft breast; grade II being a minimally firm breast; grade III being a moderately firm breast with some visible deformity; and IV being a painful, hard, distorted breast. Grades III and IV contractures typically require surgical management. This patient underwent bilateral cosmetic prepectoral saline breast augmentation. She complained of painful sagging breasts. Physical examination reported bilateral capsular contracture, without further information regarding degree of contracture. Physical examination by another provider reported no capsular contracture but noted breasts sagging over existing implants. Photographs confirm breast ptosis over breast implants, without evidence of distortion or severe breast capsular formation. There is no documentation in the medical history or photographs received for review of grade III or IV capsular contracture as a clinical cause of breast pain. Breast ptosis is not a cause of breast pain. Therefore, the requested breast implant removal surgery and breast lift surgery are not medically necessary for the patients medical condition.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; or (2) to create a normal appearance, to the extent possible. In this case, capsular contraction and sagging after cosmetic saline implant breast augmentation is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. It is not an abnormal structure of the body. The appearance of the patient is normal and consistent with cosmetic breast surgery. Accordingly, the requested breast implant removal surgery and breast lift surgery are not reconstructive in nature for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. 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.