Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right breast implant repair. Examination details, and review of the provided photographs, do not support that there is an obvious significant deformity of the patients right breast. The right breast saline implant is noted to be intact and without apparent deforming capsular contracture. Although the patient complains of pain, there is not sufficient documentation from the plastic surgeons that this is related to a significant capsular contracture or to justify surgical repair of the right breast implant. Attempts to improve the patients breast implant asymmetry at this time should be considered relatively aesthetic in nature. The plastic surgeon who evaluated the patient two weeks after mammography was performed noted that any asymmetry was related to the patients breast augmentation. Augmentation mammaplasty is a common cosmetic procedure, and complications that arise from breast implant surgery are well documented to include implant rupture and capsular contracture. Handel and colleagues state that it has become increasingly apparent in recent years that breast implant recipients experience a significant incidence of complications and a relatively high rate of reoperation. They note that in large-scale follow-up studies conducted by manufacturers, it was reported that by the end of 5 years, women undergoing augmentation with saline-filled implants had a 10 percent rate of significant (Baker grade 3 or 4) contracture. Colleagues state that capsular contracture is the most common and severe complication associated with silicone breast implants. Consequently, not only is surgical repair of the right breast implant not justified in the medical records, but any contemplated repair would be aesthetic in nature and related to a cosmetic procedure.In addition, there is not sufficient support that the mammography caused significant breast deformity or implant rupture. Ultrasound of the right breast performed shortly after mammography noted that no abnormalities were seen sonographically in the right breast. As referenced above, the plastic surgeon who evaluated the two weeks after mammography noted that any asymmetry was related to the patients breast augmentation. The plastic surgeon who evaluated the patient two months after mammography indicated that the patient has bilateral saline breast implants that are intact. Therefore, the medical records do not support that the requested surgery would be performed to correct or repair an abnormal structure of the body caused by trauma. These circumstances are also unrelated to congenital defects, developmental abnormalities, infection, tumors, or disease, and the requested services would therefore not constitute reconstructive surgery.Given the above, the requested services are not medically necessary for treatment of the patients medical condition. Furthermore, the requested services do not constitute medically necessary reconstructive surgery, as the alleged abnormality does not involve an abnormal structure of the body that was caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease.Final Result: The reviewer determined that the requested services are not medically necessary 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.