Female Breast Dis Lump Cyst: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast implant removal surgery (CPT 19371-RT, 19371-LT, 19328-RT, and 19328-LT) performed by Dr. Lisa Cassileth on 11/02/20.At issue is whether breast implant removal surgery (CPT 19371-RT, 19371-LT, 19328-RT, and 19328-LT) performed by Dr. Lisa Cassileth on 11/02/20 was medically necessary for treatment of the patient’s medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible?

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mastopexy (CPT 19371) and breast reduction (CPT 19318). Findings: The physician reviewer found that Cabral and colleagues state that, “Women with increased breast size experience symptoms such as pain in the neck, shoulders and lumbar spine, headache, intertrigo in the inframammary fold, difficulty in performing daily activities, paresthesia in the hands, difficulty in exercising, low self-esteem, and body dissatisfaction.” The American Society of Plastic Surgeons (ASPS) states that reduction mammaplasty authorization should be based on documentation of the severity of the symptoms of macromastia and impact on health-related quality of life with at least two of the following signs: (1) chronic breast pain due to weight of the breasts; (2) intertrigo unresponsive to medical management; (3)…

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast surgery (right breast capsulectomy, bilateral mastopexy, and bilateral breast implant replacement with approved bilateral implant removal and left capsulectomy). Florin and Halavy noted that, “Capsular contracture is a troublesome complication of breast implants which may require revision surgery. Capsular contracture initially presents with firmness of the breast and can progress to pain and distortion of the breast shape and volume.” Swanson commented that, “The role of capsulectomy is unclear in this patient group because there is no known physical cause for BII [breast implant illness].” Atiyeh and Emsieh stated that en bloc capsulectomy “is of no benefit in the absence of severe capsular contracture or malignancy” and “it is not supported by any scientific data.” Capsular contr…

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for mastectomy revision and/or chest reconstruction (CPT codes 19371, 19316, 19380, and/or 19340). The records provided for review document that this patient has prepectoral implants. She presents with complaints of erythema, coolness of the skin, and pain in the skin overlying her breast implants with strenuous physical activities. She underwent fat grafting in October 2019 with relief of blanching and vasospasm with activities such as playing tennis. She reports that she still experiences pain and circulation issues when she is physically active for several hours. The patient is concerned about having textured breast implants and wishes to exchange them for smooth implants.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for female breast dis lump cyst was denied, the published record says the denial is worth fighting.