Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast implant removal. In the peer-reviewed medical literature, Researchers noted that although silicone implants are now routinely used in breast surgery they have previously been the subject of controversy. On review of available data, the authors concluded that, silicone breast implants are associated with a high degree of patient satisfaction and low rates of complications. Scientists found that the evidence remains inconclusive about any association between silicone gel implants and long-term health outcomes. As noted by researchers, the Baker classification system is used to determine the severity of capsular contracture. The authors noted that grade II contracture are considered not clinically significant. The records provided for review document that this patient underwent placement of silicone gel breast implants in 2002. She now presents with a grade II contracture. Magnetic resonance imaging (MRI) demonstrated intact silicone gel implants with no evidence of implant rupture. She reports multiple generalized complaints. Current data do not support a causal association of the patients symptoms with the presence of silicone gel breast implants. The patient reports difficulty reaching above her head to perform activities such as dressing, cooking, sleeping and exercise. However, the records do not support that the patients functional deficits are due to silicone gel breast implants. Based on the medical information received for review, the requested breast implant removal 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; or (2) to create a normal appearance, to the extent possible. Silicone gel implants are not abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumor, or disease. In addition, there is a lack of evidence of a functional loss due to silicone gel implants. No photographs were received for review, and there is no report that the appearance of the patients appearance is not within normal range. Thus, the requested procedure is not likely to create a more normal appearance to the extent possible. Given these findings, the requested breast implant removal is not reconstructive in nature for treatment of 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.