Diagnosis: Breast Ductal Carcinoma in situ

Treatment: Nerve Repair with Allograft (tissue graft from a donor) or Synthetic (produced by chemicals), Nipple-Sparing; billing code 64910

The insurer denied the nerve repair with allograft (tissue graft from a donor) or synthetic (produced by chemicals), nipple-sparing; billing code 64910.

The denial was upheld.

This is a female patient who was diagnosed with ductal carcinoma in situ in one breast by Mammogram, MRI and biopsy. Bilateral mastectomies with immediate breast reconstruction, axillary node dissection, nipple sparring mastectomies with immediate sensory nerve reconstruction with allograft is being considered.

Several studies show that nipple areola sensation is diminished following nipple sparing mastectomy, and loss of nipple sensation negatively affects patient satisfaction following nipple sparing mastectomy. According to Peled and Peled: "While newer breast reconstruction approaches utilizing nipple-sparing mastectomy (NSM) techniques and immediate reconstruction can provide excellent aesthetic outcomes, absent postoperative sensation remains a major limitation¿Nerve grafting in conjunction with careful nerve preservation at the time of NSM and implant-based breast reconstruction is safe and effective with a 90% rate of preserved sensation. With longer follow-up, continued return of sensation or possibly improved sensation from baseline can be reasonably anticipated." This is the only peer reviewed study on nerve reconstruction following nipple sparing mastectomy and had only 18 patients. According to a review by Ducic et al: "Contemporary reconstructive modalities focus on breast anatomy and attempt to reconstruct breasts that are soft, of adequate shape, size, and symmetry. However, a functional component, i.e. sensation, has largely been ignored. Flap neurotization addresses this shortcoming. While we are still in search of the ideal surgical technique to achieve this goal..." The peer literature is not sufficient to confirm efficacy.

While Nerve allograft is approved by the FDA and the patient is a good candidate for nerve reconstruction, the scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. There is insufficient peer evidence to support this procedure. This service is not likely to be more beneficial than any other standard procedure.

The denial of nerve repair with allograft (tissue graft from a donor) or synthetic (produced by chemicals), nipple-sparing; billing code 64910 is upheld.