Breast Implant Removal denials in California external review

What the reviewers wrote

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 reimbursement for breast implant removal services performed.Findings: The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines “emergency services and care” as “medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility.” A screening examination in an emergency department, and any medical…

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the removal of the right breast implant. Medical literature notes 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.” The authors noted that “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.” Medical literature establishes that “The degree of contracture is clinically graded by the grading system.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast implant removal surgery. Florin and Halavy report that capsular contracture is a troublesome complication of breast implants, which may require revision surgery, that initially presents with firmness of the breast and can progress to pain and distortion of the breast shape and volume. The authors further explain that when an implant is placed, a fibrous capsule forms around it and while in a normal breast, the capsule is thin and soft, without 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.

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 Breast Implant Removal, then check the rights and deadlines that apply to your plan.