Diagnosis: Status post left mastectomy.
Treatment: code 11954-LT (left side), subcutaneous injection of filling material; over 10.0 cc (cubic centimeter).
The insurer denied coverage for code 11954-LT (left side), subcutaneous injection of filling material; over 10.0 cc.
The denial is upheld.

This is an adult female with a history of failed left breast reconstruction. The patient currently has a left chest wall deformity and no breast reconstruction. The submitted code does not accurately describe the procedure performed. Fat grafting is a stage of the patient's reconstruction following mastectomy and the women's health and cancer rights act (WHCRA) mandates coverage for all stages of breast reconstruction. Therefore, fat grafting was an appropriate reconstructive procedure for this patient's post-mastectomy deformity. Longo et. al. describe total post-mastectomy breast reconstruction with fat grafting alone. The procedure performed for this patient is an accepted standard of care for breast reconstruction. However, fat grafting is coded as follows:

Current Procedural Terminology (CPT) codes 15771 (Grafting of autologous fat harvested by liposuction technique) and 15772 (add-on code for autologous fat grafting to the trunk, breasts, extremities, or scalp for each additional 50cc of injectate) can be used to report fat grafting to the breast.

Procedure 11954-LT was not performed. Code 11954 is used for the injection of a filler such as collage or Juvaderm. The CPT code for fat grafting is 15771. Fat grafting was medically necessary, but the submitted CPT code was not performed and therefore is not medically necessary.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the code 11954-LT, subcutaneous injection of filling material; over 10.0 cc is upheld. Medical Necessity is not substantiated.