Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral breast implants with breast lift (mastopexy). Complications that arise from breast implant surgery are well documented to include implant rupture and capsular contracture. Researchers 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. Researchers state that capsular contracture is the most common and severe complication associated with silicone breast implants.In this case, the patient underwent bilateral capsulectomy, the removal of the patients original ruptured implants, replacement with smaller implants, and bilateral breast lift. The Health Plan authorized coverage for the removal of the ruptured breast implants, but denied reimbursement for bilateral breast implants with breast lift (mastopexy). The patient has a history of breast augmentation for apparent cosmetic concerns. The patient underwent standard treatment of a typical complication (implant rupture) following cosmetic surgery, namely breast augmentation. Breast augmentation is a common cosmetic procedure. As noted in the referenced medical literature, complications that arise from this surgery are well documented to include implant rupture and capsular contracture. The disputed procedures that were performed (bilateral breast implants with breast lift/mastopexy) are typical treatment of cosmetic surgery complications and for other aesthetic concerns.In addition, the patients condition did not constitute an abnormal structure of the body, as the condition being treated with implant replacement and mastopexy was one due to the patients history of augmented breasts for cosmetic intervention. This would not be considered an abnormal structure of the body, but rather involves issues that relate to aesthetic enlargement of the breasts.Given the above, the bilateral breast implants with breast lift (mastopexy) were not medically necessary for treatment of the patients medical condition. Furthermore, the bilateral breast implants with breast lift (mastopexy) were not reconstructive surgery that involved 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 services at issue were 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.