Reduction Mammoplasty

POLICY NUMBER

L.7.01.423

DESCRIPTION

Reduction mammoplasty is the surgical excision of a substantial portion of the breast, including the skin and the underlying glandular tissue, until a clinically normal size is obtained. Because breast are paired organs and macromastia generally affects both sides, bilateral surgery is usually performed.

Occasionally, when there is significant, one-sided hypertrophy, a unilateral breast reduction is performed. Such a procedure may also be needed to match the contralateral side when the opposite breast has been reconstructed after mastectomy (reconstruction).

Reduction mammoplasty is similar to mastopexy, since nearly all hypertrophic breasts are ptotic and must be lifted during correction.

Although various techniques have been developed for breast reduction, nearly all require a pedicle to carry the nipple areola to its new position and a circumareolar incision as well as an inverted T incision beneath the areola. In gigantomastia, the nipple-areola is often removed as a free full-thickness graft and positioned appropriately.

POLICY

Cosmetic procedures are not considered eligible for coverage. Cosmetic services do not become eligible for coverage because of psychiatric or emotional problems.

Liposuction, using any method for any condition including obesity and reduction mammoplasty, is considered cosmetic.

Reconstructive procedures are considered eligible for coverage. To be considered medically necessary, there must be documentation that the procedure is to be performed to restore bodily function or correct deformity resulting from disease, trauma, or complication of previous non-cosmetic surgery. If this documentation is not present, the procedure should be considered cosmetic and not covered.

The following will be reviewed for a determination as to whether the procedure is cosmetic or reconstructive:

• Patient's height and weight

• Symptomatology and duration

• Anticipated amount of breast tissue to be removed

In accordance with the Women's Health and Cancer Rights Act of 1998 (WHCRA), all group health insurance as well as individual contracts that provide coverage for a mastectomy must comply with the following requirements:

If the Member elects reconstructive breast surgery connected with any medically necessary mastectomy, benefits will be provided for the following covered services:

• Reconstruction of the breast on which the mastectomy was performed

• Surgery on the unaffected breast that is required to "produce a symmetrical appearance" and

• Prostheses and treatment of complications of any state of a mastectomy, including lymphedema.

Females

Bilateral reduction mammoplasty in a female is considered medically necessary and not cosmetic when all of the following clinical indications and/or physical findings listed below are present. Anyone under 15 years of age must have a primary care physician referral or consult. This evaluation should be a part of the requesting physician’s chart. In addition, all of the following items must be documented in the requesting physician’s chart.

1. This procedure is eligible for coverage in a female when documentation is provided that describes treatment for specific symptomatology related to excessive breast size. Justification for reduction mammoplasty should be based on the probability of relieving the clinical signs and symptoms of macromastia.

2. Women with large breasts, (i.e. DD cup and/or breast(s) that hang to the umbilicus) who have pain in the upper back, neck and shoulders, resulting in documented work loss and interference with activities of daily living. The pain should not be associated with another diagnosis (for example, arthritis).

3. Ulceration of skin of shoulder or shoulder/clavicular grooving not responding to conservative treatment, including support bra or intertrigo between the pendulous breast and the chest wall.

4. A copy of the chart for the previous six months of a patient's office visits should reflect the patient's height and weight, the anticipated amount of breast tissue to be removed, and that the size and shape of the breast is causing the symptoms.

5. Resection of the minimum grams of breast tissue or more per breast is required as documented per pathology report. (See the following chart).

Unilateral reduction mammoplasty in a female over the age of 18 is considered medically necessary and not cosmetic when all of the following clinical indications and/or physical findings are present:

1. Resection of the minimum grams of breast tissue or more is required (as listed in the chart above)

2. Female Sexual Maturation, Tanner Stage 5 (as listed in the chart below)

1. Augmentation is not covered, regardless of medical necessity.

Males

Mastectomy for gynecomastia in a male over the age of 18 is medically necessary if the tissue removed is glandular breast tissue and not the result of obesity, adolescence, or reversible effects of drug treatment which can be discontinued. Removal of fatty tissue is considered cosmetic.

In males, exogenous sources of estrogen must be sought before consideration of surgery. If an endocrine workup is negative and the exceptions listed below are not present, surgery may be considered.

Removal of breast tissue in the male for gynecomastia is not covered when resulting from any of the following:

1. Obesity: defined as greater than 10% of the ideal body weight according to the most recently published Metropolitan Life Insurance Tables.

2. Drug treatment which can be discontinued. Examples include, but are not limited to, ketoconazole, digitalis, spironolactone, cimetidine, chemotherapeutic agents, excess testosterone or illicit drugs such as marijuana, heroin, steroids.

3. Prepubertal gynecomastia resulting from indirect exposure to estrogen cream (from mother, female caregiver, etc.).

4. Adolescence: Defined as an age of <18 and a sexual maturity rating (SMR) of ,5, as defined by the following Tanner Classification:

POLICY EXCEPTIONS

For Federal Employee Program (FEP) Subscribers: Surgical treatment of bilateral gynecomastia is considered not medically necessary.

Reduction mammoplasty may be considered medically necessary for the treatment of macromastia when well-documented clinical symptoms are present, including but not limited to:

• Documentation of a minimum 6-week history of shoulder, neck, or back pain related to macromastia that is not responsive to conservative therapy, such as an appropriate support bra, exercises, heat/cold treatment, and appropriate non-steroidal anti-inflammatory agents/muscle relaxants.

• Recurrent or chronic intertrigo between the pendulous breast and the chest wall.

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B. appropriate with regard to standards of good medical practice; and

C. not solely for the convenience of the Member, his or her Provider; and

D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

POLICY HISTORY

2/1993: Approved by Medical Policy Advisory Committee (MPAC)

9/23/1999: Interim policy enacted

11/1999: Interim policy changes approved by MPAC

5/21/2001: Code Reference revised

7/16/2001: Mastectomy for gynecomastia clarification

10/4/2001: #4 under "Males" age changed from 15 to <18; SMR changed to <5

1/2002: Prior authorization deleted

3/26/2002: References to the Master Contract deleted

5/2/2002: Type of Service and Place of Service deleted

5/9/2002: Policy section revised (# 2, 4, 5, 6, 7, signs/symptoms, required minimum grams), headache and pendulousness added to cosmetic signs and symptoms

5/16/2002: MPAC reviewed and revised policy, unilateral reduction mammoplasty covered based on criteria listed, breast asymmetry deleted as cosmetic. Sources updated

5/28/2002: Metropolitan Life Insurance Tables hyperlink added

6/20/2002: # 3 under bilateral mammoplasty "bra or intertrigo"

3/2003: Reviewed by MPAC, no changes, "Intertrigo" bullet under cosmetic signs and symptoms deleted, Sources updated

6/10/2003: Code Reference section updated, ICD-9 611.71, 784.0 deleted

7/2003: Reviewed by MPAC, no changes

7/15/2004: Policy reviewed by MPAC, the following changes will be effective November 1, 2004: Under FEMALES; age 18 requirement for bilateral reduction mammoplasty deleted, “Anyone under 15 years of age must have a primary care physician referral or consult for bilateral reduction mammoplasty” added, #6 “Patients must be within 20% of ideal body weight as defined by the most recent published Metropolitan Life Insurance Tables.” deleted from bilateral reduction mammoplasty, “cosmetic signs and symptoms for males and females include breast pain and/or tenderness, ptosis, nipple-areolar distortion, poor posture, inability to lose weight in the breasts, social embarrassment, inability to participate in normal physical activities, poorly fitting clothing, unacceptable appearance, headaches and pendulousness” deleted, FEP exception added, Sources updated

8/11/2004: Code Reference section reviewed, no changes

10/7/2004: Code Reference section updated, non-covered table and code range 278.00-278.01 deleted, WHCRA added

10/21/2004: Metropolitan Life Height and Weight Tables added

11/18/2004: Reviewed by MPAC, no changes

7/21/2005: Code Reference section reviewed, no changes

2/20/06: Photographic submission requirement removed from policy

4/11/2006: Policy clarification

1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions

3/26/2007: Policy reviewed, no changes

9/19/2008: Annual ICD-9 updates effective 10-1-2008 applied

3/26/2009: Reviewed by the Medical Policy Advisory Committee (MPAC). "Failure of pain to be relieved by a six-week course of conservative therapy, including an appropriate support bra, exercise, heat/cold treatment, and appropriate non-steroidal anti-inflammatory agents/muscle relaxants" requirement removed from the policy.

01/29/2013: For clarity purposes, the Patient Height table was revised in the Policy section to add the verbiage "but not to include" for heights 5'0" through 5'8". The verbiage "inclusive and" was added for height 5'9" and over. Intent of policy statement unchanged.

03/07/2014: Policy reviewed; no changes

08/14/2015: Updated the Policy Exceptions section regarding reduction mammoplasty and surgical treatment of gynecomastia.

08/27/2015: Code Reference section updated for ICD-10. Removed deleted ICD-9 diagnosis code 611.8.

06/01/2016: Policy number L.7.01.423 added.

12/18/2020: Code Reference section updated to revise description for CPT code 19318, effective 01/01/2021.

04/28/2022: Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity." Code Reference section updated to remove the Metropolitan Life Height and Weight Tables.

01/24/2023: Policy reviewed; no changes.

02/15/2024: Policy reviewed; no changes.

03/13/2025: Policy reviewed; no changes.

SOURCE(S)

1. American Society of Plastic and Reconstructive Surgeons, Inc. Position Paper 11/1987 & 7/1991

2. American Society of Plastic Surgeons Recommend Insurance Coverage Criteria for Third-Party Payers/Patient Care Parameters

3. Blue Cross Blue Shield Association policy # 7.01.21

4. Division of Medicaid State of Mississippi, section 53.06

5. http://www.regence.com/trgmedpol/surgery/sur60.html

6. Kerrigan, C.L., MD, Collins, E. D., MD, Kim, H.M., MD, Schnur, P.L., MD, Wilkins, E., MD, Cunningham, B., MD., et al. (2002) Reduction Mammoplasty: Defining Medical Necessity. Medical Decision-Making, May-June, 208-217.

7. Kerrigan, C.L., MD, Collins, E. D., MD, Kim, H.M., MD, Schnur, P.L., MD, Wilkins, E., MD, Cunningham, B., MD., et al. (2002) The Effectiveness of Surgical and Nonsurgical Interventions in Relieving the Symptoms of Macromastia. Plastic and Reconstructive Surgery, Vol. 109, No. 5, 1556-1566.

8. Medical Policy Advisory Committee (2/1993)

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Covered Codes

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