Capsular Contracture denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast implant removal, bilateral capsulectomy, bilateral breast reconstruction, and bilateral reinsertion of breast implants to be performed in one surgical procedure. Researchers state 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. 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. Grade III and IV contractures typically require surgical management.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reconstruction revision/exchange bilateral breast implants for treatment of the enrollee’s congenital marked asymmetry of the breasts and reconstructive in nature. Findings: The physician reviewer found that congenital breast deformity is a well-recognized condition that may be amenable to breast reconstruction. In this patient’s case, she has a painful capsular contracture that can be considered a complication of her original reconstructive surgeries. Thus, the proposed surgery is considered medically necessary to treat a functional impairment. Further, as stated by the American Society of Plastic Surgeons (ASPS), attempts at correction of these deformities should be considered reconstructive surgery.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral peri-implant capsulectomy and bilateral breast implant removal. Capsular contracture is a complication of breast implants that may require revision surgery. The authors noted that “Capsular contracture initially presents with firmness of the breast and can progress to pain and distortion of the breast shape and volume. When an implant is placed, a fibrous capsule forms around it. In a normal breast, the capsule is thin and soft, with no effect on the appearance of the breast. In a contracted breast, the capsule becomes thick and hard, and shrinks in a way which alters the contour of the breast and the position of the implant.” A study describes the Baker classification of capsular contracture after breast augmentation. Grade I capsular contracture is asymptomatic.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal of bilateral breast implants with complete peri-implant capsulectomy and bilateral mastopexy. Regarding capsulectomy, this patient presents with a ruptured saline implant. The presence of the deflated saline implant is as harmless as the presence of the intact implant, and it is nonpalpable and asymptomatic for this patient. Explantation of a collapsed saline breast implant is not indicated. There is a lack of report of physical findings or photographic documentation of a grade IV capsular contracture on the right breast. As noted by one study, explantation would be appropriate without capsulectomy. Percutaneous needle deflation would also be appropriate given the saline implant deflation on the contralateral side.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving capsular contracture, then check the rights and deadlines that apply to your plan.