(For guidelines regarding gynecomastia (male breast reduction) surgery, please see policy #658)
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:
- 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 (Modified Schnur Nomogram), 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 when using 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.
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.
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.
Such coverage may be subject to annual deductibles and co-insurance provisions as may be deemed appropriate and are consistent with those established for other benefits under the plan or coverage. Written notice of the availability of such coverage shall be delivered to the participant upon enrollment and annually thereafter. For additional information, please call (800) 421-1362.