BlueAdvantage Administrators of Arkansas
Coverage Policy#: 282
Category: Surgery
Initiated: January 2004
Last Review: September 16, 2024
Last Revision: September 16, 2024
BlueAdvantage National Accounts
Coverage Policy for Participants and Beneficiaries enrolled in Walmart Associates' Health and Welfare Medical Plan
(Developed by BlueAdvantage Administrators and Adopted by the Walmart Plan as Plan Coverage Criteria)

Reduction Mammaplasty


Description:
Macromastia, or gigantomastia, is a condition that describes breast hyperplasia or hypertrophy. Macromastia may result in clinical symptoms such as shoulder, neck, or back pain, or recurrent intertrigo in the mammary folds. Also, macromastia may be associated with psychosocial or emotional disturbances related to the large breast size.
 
Reduction mammaplasty is a surgical excision of a substantial portion of the breast, including the skin and underlying glandular tissue, that is designed to remove a variable proportion of breast tissue to address emotional and psychosocial issues and/or to relieve the associated clinical symptoms. It may reduce the size, change the shape, and/or lift the breast tissue.
 

Policy/
Coverage:
(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:
 
    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 (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.
 
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.
 
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.
 

Rationale:
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.
 
 
2011 Update:
A Medline review of medical literature did not identify any information that would result in a change in the current coverage policy statement.
 
2012 Update
A Medline review of medical literature did not identify any information that would result in a change in the current coverage policy statement.
 
2014 Update
 
A literature search conducted through March 2014 did not reveal any new information that would prompt a change in the coverage statement.
 
 
2015 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.
 
2019 Update
A literature search was conducted through June 2019.  There was no new information identified that would prompt a change in the coverage statement.  
 
2020 Update
A literature search was conducted through June 2020.  There was no new information identified that would prompt a change in the coverage statement.  
 
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through June 2021. No new literature was identified that would prompt a change in the coverage statement.
 
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through June 2022. No new literature was identified that would prompt a change in the coverage statement.
 
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through June 2023. No new literature was identified that would prompt a change in the coverage statement.
 
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2024. No new literature was identified that would prompt a change in the coverage statement.

CPT/HCPCS:
19318Breast reduction

ICD9:
611.1Hypertrophy of breast
707.8Chronic ulcer of other specified site
719.41Pain in joint, shoulder region
724.5Unspecified backache
V10.3Personal history of malignant neoplasm of breast

ICD10:
L98.491Non prs chronic ulcer skin/ sites limited to brkdwn skin
M25.511Pain in right shoulder
M25.512Pain in left shoulder
M25.519Pain in unspecified shoulder
M54.89Other dorsalgia
M54.9Dorsalgia, unspecified
N62Hypertrophy of breast
Z85.3Personal history of malignant neoplasm of breast

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.

Cunha MS, Santos LL, et al.(2011) Evaluation of pulmonary function in patients submitted to reduction mammoplasty. Rev Col Bras Cir, 2011; 38:11-14.

Dafydd H, Roehl KR, et al.(2011) Redefining gigantomastia. J Plast Reconstr Aesthet Surg, 2011; 64:160-3.

Ducic I, Iorio ML, Al-Attar A.(2010) Chronic headaches/migraines: extending indications for breast reduction. Plast Reconstr Surg, 2010; 125:44-9.

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.

Hernanz F, Santos R, et al.(2010) Treatment of symptomatic macromastia in a breast unit. World J Surg Oncol, 2010; 8:93-8.

Koltz PF, Sbitany H, et al.(2011) Reduction mammoplasty in the adolescent female: the URMC experience. Int J Surg, 2011; 9:229-32.

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.

Saariniemi KM, Joukamaa M, et al.(2009) Breast reduction alleviates depression and anxiety and restores self-esteem: a prospective randomised clinical trial. Scand J Plast Reconstr Surg Hand Surg, 2009; 43:320-4.

Spector JA, Singh SP, Karp NS.(2008) Outcomes after breast reduction: does size really matter? Ann Plast Surg, 2008; 60:505-9.

Webb ML, Cerrato F, et al.(2011) The effect of obesity on early outcomes in adolescents undergoing reduction mammoplasty. Ann Plast Surg, 2011; [epub ahead of print].


The Walmart Plan is a self-funded health plan served by BlueAdvantage Administrators and has adopted all of the Coverage Policies listed here as benefit criteria applicable to its health plan.

CPT Codes Copyright © 2024 American Medical Association.
282 7.01.21 202409 9/30/2024