Coverage Policy Manual
Policy #: 1997192
Category: Surgery
Initiated: August 1993
Last Review: July 2018
  Mammoplasty, Reduction

Description: A surgical excision of a substantial portion of the breast, including the skin and underlying glandular tissue, may reduce the size, change the shape, and/or lift the breast tissue.

Policy/
Coverage:
Effective October 2012
 
Breast Reduction: Any expenses or charges resulting from female breast reduction(s) are not covered, unless directly related to treatment of a mastectomy, partial mastectomy, or lumpectomy (as provided below), or unless the Plan conducts a medical review and determines that the procedure is medically necessary.
 
The Women’s Health and Cancer Rights Act (WHCRA) of 1998, requires the plan provide coverage for:
 
1. All stages of reconstruction of the breast on which the mastectomy has been performed;
2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
3. Prostheses and physical complications of mastectomy, including lymphedema, in a manner determined in consultation with the attending physician and the patient.
 
Breast reduction is a covered service in the non-diseased breast to achieve symmetry following contralateral mastectomy, partial mastectomy, or lumpectomy, based on the WHCRA regulations.
 
Breast reduction may also be covered in females for whom growth is complete (18 years of age or older) who have enlarged breasts (macromastia) when the following criteria have been met:
 
    1. Any of the following symptoms for at least 12 months (as documented in the patient’s records):
          • Persistent symptoms in at least 2 of the following anatomical areas:
              • Pain in neck,
              • Pain in shoulders,
              • Pain in upper back,
              • painful kyphosis documented by x-rays,
              • ulnar paresthesias; OR
          • Intertriginous maceration of the inframammary skin unresponsive to medical therapy; OR
          • Shoulder notching with pain, ulceration.
AND
 
2. When the total amount of breast tissue as noted in the chart below has been removed.
 
 
The surgeon estimates the following amounts of breast tissue in grams, will be removed from each breast based on body surface area (BSA) and the Schnur Sliding Scale that follows.
 
Information for use with the Schnur Nomogram Chart below:
 
This Schnur chart may be used to assess whether the amount of tissue that will be removed is reasonable for the body habitus, and whether the procedure is cosmetic or reconstructive in nature.
 
1. If the amount plots above the 22nd percentile, and other cocriteria are met, breast reduction would be allowed;
2. If the amount plots below the 5th percentile, breast reduction for macromastia is considered cosmetic;
3. If the amount plots between the 5th and 22nd percentiles, the procedure will be reviewed to determine medical necessity.
 
To calculate body surface area (BSA) see http://www.halls.md/body-surface-area/bsa.htm OR the BSA may be calculated using BSA = (W 0.425 x H 0.725) x 0.007184 (weight is in kilograms and the height is in centimeters.)
 
Modified Schnur Nomogram Chart
 
Tissue removed per breast (gm)
 
Body Surface (m2)………….Lower 5th percentile…………….Lower 22nd percentile
 
1.35………………..…………….127………………..…………….199
1.40………………..…………….139………………..…………….218
1.45………………..…………….152………………..…………….238
1.50………………..…………….166………………..…………….260
1.55………………..…………….181………………..…………….284
1.60………………..…………….198………………..…………….310
1.65………………..…………….216………………..…………….338
1.70………………..…………….236………………..…………….370
1.75………………..…………….258………………..…………….404
1.80………………..…………….282………………..…………….441
1.85………………..…………….308………………..…………….482
1.90………………..…………….336………………..…………….527
2.00………………..…………….401………………..…………….628
2.05………………..…………….439………………..…………….687
2.10………………..…………….479………………..…………….750
2.15………………..…………….523………………..…………….819
2.20………………..…………….572………………..…………….895
2.25………………..…………….625………………..…………….978
2.30………………..…………….682………………..…………….1,068
2.35………………..…………….745………………..…………….1,167
2.40………………..…………….814………………..…………….1,275
2.45………………..…………….890………………..…………….1,393
2.50………………..…………….972………………..…………….1,522
2.55………………..…………….1,062 ………………..…………1,662
 
Table and nomogram were originally published in Schnur PL et al. Reduction mammaplasty: cosmetic or reconstructive procedure? Ann Plast Surg. 1991 Sep;27(3):232-7.
 
NOTE: Medical review of breast reduction will require contemporaneous physician office notes that include a history of the complaint, a physical examination and notes regarding previous evaluations and testing. This documentation should note the patient’s bra size, height, and weight. Frontal and side photographs showing macromastia should be available for review if requested.
 
Effective prior to October 2012
Reduction mammoplasty is considered a covered service when one of the following physical findings is present and documented in the medical record:
    • Back pain of at least 6 months duration that is unresponsive to conservative treatment and not due to causes other than increased breast weight;
    • Intertrigo beneath the breast that is unresponsive to conservative treatment.
 
Frontal and lateral view photographs showing macromastia should be available for review in the patient's chart.
 
Minimum proposed specimen weights (both breasts combined) (glandular tissue) should be 0.4 kg for women weighing less the 60 kg (132#), 0.7 kg for women weighing 60-80 kg (132-176#), and 1 kg for women weighing more than 80 kg (176#).
 
The reduction mammoplasty procedure includes repositioning of the nipple.  
 
Diagnostic mammography meets primary coverage criteria for effectiveness and is covered prior to surgery for women:
    • Over age 30 years to uncover an unsuspected breast cancer or to direct a diagnostic biopsy prior to breast reduction surgery; or
    • With a family history of breast cancer in first degree maternal relatives.  
 
Asymmetry of the breasts, intertrigo responsive to conservative therapy, ptosis of the breasts, poorly fitting clothing, or unacceptable appearance are not valid reasons for coverage for reduction mammoplasty, except for surgery on the contralateral breast following mastectomy.
 
Liposuction alone to perform this surgery is considered cosmetic and not covered.  Cosmetic services are an exclusion in the member benefit contract.

Rationale:
2002 Update
A search of the literature based on the MEDLINE database was performed for the period of 1995 to 2002. While the literature search identified several articles that discuss the surgical technique of reduction mammaplasty and document that reduction mammaplasty is associated with a relief of physical and psychosocial symptoms, the medical policy has always focused on the distinction of whether the proposed reduction mammaplasty is medically necessary or cosmetic in nature. For some patients the presence of medical indications is clear-cut, i.e., a clear documentation of recurrent intertrigo, or ulceration secondary to shoulder grooving. However, for the majority of patients, the documentation between a cosmetic and medically necessary procedure will be unclear and subjective in nature. Criteria for medically necessary reduction mammaplasty are not well addressed in the published medical literature, and thus the optimal patient selection criteria cannot rely on an evidence-based approach. Therefore, the policy guidelines do not endorse a particular set of patient selection criteria, i.e. the use of photographs, amount of breast tissue removed, or a combination of approaches.
 
The following discussion focuses the published literature addressing the use of weight of excised breast as coverage criteria. In 2001, Krieger and colleagues reported on a survey of managed care policies regarding reduction mammaplasty.  Most of the respondents to the survey stated that they use weight of excised tissue as the main criterion for allowing the procedure. The average cut-off value for this determination was 472 g. While 500 g. appears to be a commonly cited cut-off weight of excised tissue, there appears to be no documentation in the literature as to the sensitivity and specificity of this value in distinguishing cosmetic from medically necessary procedures.  Also, the use of a single weight cut-off does not address the issue of the relationship between body surface area and weight of excised tissue. In 1991, Schnur and colleagues, at the request of third party payors, developed a sliding scale.  This sliding scale was based on survey responses of 92 of 200 solicited plastic surgeons, who reported the height, weight, and amount of breast tissue removed from each breast from the last 15 to 20 reduction mammaplasties that had been performed. The surgeons were also asked if the procedure were performed for cosmetic or medically necessary reasons. The data were then used to create a chart relating the body surface area and the cutoff weight of breast tissue removed according to the 5th percentile and 22nd percentile lines. Based on their estimates, those with breast weight above the 22 percentile line likely had the procedure performed for medical reasons, while those below the 5 percentile line likely had the procedure performed for cosmetic reasons, and those falling between the lines had the procedure formed for mixed reasons.
 
In 1999, Schnur reviewed the experience of the sliding scale as a coverage criterion, and reported that while many payors had adopted this scale, many had also misused it.  The author pointed out that if a payor uses weight of resected tissue as a coverage criteria, then if the weight falls below the 5th percentile line the reduction mammaplasty would be considered cosmetic, above the 22nd percentile line would be considered medically necessary, and those that fell between these lines would be considered on a case by case basis. The author also questions the frequent requirement that a woman be within 20% of her ideal body weight. While weight loss might indeed relieve symptoms, durable weight loss is notoriously difficult and may be unrealistic in many cases.
 
2014 Update
A literature search conducted through October 2014 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
Retrospective evaluations of large population datasets have reported an increased incidence of perioperative and postoperative complications with high BMI (Nelson, 2014; Gust, 2013).
 
2016 Update
A literature search conducted through June 2016 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
Beraldo and colleagues reported trial of 60 patients randomized to receive either reduction mammaplasty or no operation (Beraldo, 2014). The outcomes of this study were sexual function and depressive symptoms. At 6 months, Female Sexual Function Index scores were higher in the reduction mammaplasty group (27.5 vs 22.5, p<0.001). Level of depression as measured by the Beck Depression Inventory was lower in the reduction mammaplasty group (7.2 vs 13.7, p=0.01). Analyses using categories of sexual function or depression showed similar results.
 
2017 Update
A literature search conducted through June 2017 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
In 2016, Hernanz and colleagues reported on a descriptive cohort study of 37 consecutive obese patients who underwent reduction mammoplasty for symptomatic macromastia, along with 37 age-matched women hospitalized for short-stay surgical procedures (Hernanz, 2016). In the preoperative state, SF-36 physical health component subscore was significantly lower for patients with symptomatic macromastia (40) than for age-matched controls (53; p<0.001), with differences in 5 of the 8 subscales. At 18 months postprocedure, there was no significant difference in any SF-36 subscores except the body pain subscale between patients who had undergone reduction mammoplasty and age-matched controls.
 
ONGOING AND UNPUBLISHED CLINICAL TRIALS
A search of ClinicalTrials.gov in May 2017 did not identify any ongoing or unpublished trials that would likely influence this review.
 
2018 Update
A literature search was conducted through June 2018.  There was no new information identified that would prompt a change in the coverage statement.

CPT/HCPCS:
19318Reduction mammaplasty

References: Beraldo FN, Veiga DF, Veiga-Filho J, et al.(2014) Sexual function and depression outcomes among breast hypertrophy patients undergoing reduction mammaplasty: a randomized controlled trial. Ann Plast Surg. Dec 19 2014. PMID 25536204

Dabbah A, Lehman JA, Parker MG, et al.(1995) Reduction mammaplasty: an outcome analysis. Ann Plast Surg 1995; 35(4):337-41.

Glatt BS, Sarwer DB, O’Hara DE, et al.(1999) A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Plast Reconstr Surg 1999;103(1):76-85.

Gust MJ, Smetona JT, Persing JS, et al.(2013) The impact of body mass index on reduction mammaplasty: a multicenter analysis of 2492 patients. Aesthet Surg J. Nov 1 2013;33(8):1140-1147. PMID 24214951

Hernanz F, Fidalgo M, Munoz P, et al.(2016) Impact of reduction mammoplasty on the quality of life of obese patients suffering from symptomatic macromastia: A descriptive cohort study. J Plast Reconstr Aesthet Surg. Aug 2016;69(8):e168-173. PMID 27344408

Hidalgo DA, Elliot LF, Palumbo S, et al.(1999) Current trends in breast reduction. Plast Reconstr Surg 1999; 104(3):806-18.

Krieger LM, Lesavoy MA.(2001) Managed care’s methods for determining coverage of plastic surgery procedures: the example of reduction mammaplasty. Plast Reconstr Surg 2001;107(5):1234-40.

Myung Y, Heo CY.(2016) Relationship Between Obesity and Surgical Complications After Reduction Mammaplasty: A Systematic Literature Review and Meta-Analysis. Aesthet Surg J. Dec 09 2016. PMID 27940905

Nelson JA, Fischer JP, Chung CU, et al.(2014) Obesity and early complications following reduction mammaplasty: An analysis of 4545 patients from the 2005-2011 NSQIP datasets. J Plast Surg Hand Surg. Oct 2014;48(5):334-339. PMID 24506446

Schnur PL, Hoehn JG, Ilstrup DM, et al.(1991) Reduction mammaplasty: cosmetic or reconstructive procedure. Ann Plast Surg 1991; 27(3):232-7.

Schnur PL, Schnur DP, Petty PM, et al.(1997) Reduction mammaplasty: an outcome study. Plast Reconstr Surg 1997; 100(4):875-83.

Seitchik MW.(1995) Reduction Mammoplasty: Criteria for Insurance Coverage. Plast Reconstr Surg 1995; 95:1029-1032.


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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