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.
2025 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2025. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
Lin et al conducted a systematic review of 7 RCTs (N=285) comparing reduction mammaplasty with a control intervention (nonoperation or physiotherapy exercises) for the treatment of breast hypertrophy (Lin, 2021). Four RCTs were included in meta-analyses reporting on change in pain, physical function, and psychological function after interventions. Statistically significant improvements were found in pain (standardized mean difference [SMD], -1.29; 95% confidence interval [CI], -1.63 to -0.96; p less than .00001), physical function (SMD, 0.97; 95% CI, 0.69 to 1.25; p less than .00001), and psychological function (SMD, -0.79; 95% CI, -1.07 to -0.52; p less than .00001) after mammaplasty compared to the control intervention. The authors concluded that mammaplasty had a positive and significant effect on health-related quality of life, including pain, physical, and psychological functioning, in individuals with breast hypertrophy.
Beraldo et al reported on RCT of 60 patients with breast hypertrophy who were randomly allocated to a control group (CG) (n = 30) or a breast reduction group (BRG) (n = 30) (Beraldo, 2016). The patients in the CG were assessed at the first appointment as well as 3 and 6 months later. The patients in the BRG were assessed preoperatively as well as 3 and 6 months postoperatively. Validated instruments, the Female Sexual Function Index and the Beck Depression Inventory, were used to assess sexual function and depression among the subjects. The results of these assessments were compared within and between groups. Twenty-seven and 29 patients in the CG and the BRG, respectively, completed the 6-month follow-up period. At baseline, the groups did not differ significantly with regard to the main demographic data. In the initial assessment, the groups did not differ significantly with regard to Female Sexual Function Index or Beck Depression Inventory scores. Compared with the CG, the BRG reported better sexual function 3 (P = 0.015) and 6 (P = 0.009) months postoperatively. Regarding depression scores, the reduction mammaplasty group had better results 6 months postoperatively (P = 0.014). Reduction mammaplasty positively affected sexual function and depression levels in breast hypertrophy patients.
Iwuaguwu et al reported on a RCT assessing the effects of bilateral breast reduction on anxiety and depression in women with mammary hypertrophy (macromastia) (Iwuaguwa, 2006). Seventy-three consecutive women referred for consideration for breast reduction were recruited. They were randomised to have either early operation (within six weeks of initial assessment) or delayed operation (within six months of recruitment). The Hospital Anxiety and Depression Score was given before randomisation and four months later. All 73 patients completed the study. The mean (SD) age was 39 (12) years. The groups were matched for age, smoking, social class, and educational achievement. There were highly significant improvements (p less than 0.001) in symptoms of anxiety and depression. Reduction mammaplasty significantly improved symptoms of clinical depression in women with macromastia.
Neck, shoulder, and lower back pain and reduction of functional capacity can be caused by breast hypertrophy. Reduction mammaplasty appears to improve these aspects. After a systematic review of the literature, no scientific evidence was found to confirm this hypothesis. The objective of trial reported on by Freire et al was to evaluate the impact of reduction mammaplasty on pain and functional capacity of patients with mammary hypertrophy (Freire, 2007). One hundred patients with mammary hypertrophy, between 18 and 55 years old, with no previous mammary surgery, were consecutively selected from the Plastic Surgery Outpatient Clinic of the Universidade Federal de Sao Paulo Escola Paulista de Medicina and randomly allocated into two groups. Group A (n = 50) underwent mammaplasty reduction immediately, whereas group B patients (n = 50) were placed on a waiting list (control group). All patients were interviewed for clinical and demographic data and evaluated to measure pain and functional capacity. To measure shoulder, neck, and lower back pain, a visual analogue scale (0 = no pain, 10 = unbearable pain) was used. The Stanford Health Assessment Questionnaire (HAQ-20), Brazilian validated version (0 = best, 3 = worst), was applied to assess functional capacity. Pain and functional capacity were measured at baseline and 6 months after surgery. Forty-six of 50 patients, from both groups, completed the study. The mean (+/-SD) patient age in groups A and B was 31.6 +/- 11 and 32.3 +/- 10 years, respectively. The mean breast tissue weight was 1052 +/- 188 g. Functional capacity in group A was improved 6 months after reduction mammaplasty, compared with group B (control), in the following aspects: getting dressed, getting up, walking, maintaining personal hygiene, reaching, and grasping objects. The mean pain intensity dropped in the lower back, from 5.7 to 1.3; in the shoulders, from 6.1 to 1.1; and in the neck, from 5.2 to 0.9. Reduction mammaplasty improved functional capacity and relieved pain in the lower back, shoulders, and neck of patients with mammary hypertrophy.
Of women who seek reduction mammaplasty, up to a third have pathological degrees of anxiety or depression, or both. The psychological aspect of reduction mammaplasty is therefore an important consideration. Saariniemi et al reported on a prospective randomised clinical trial to see how reduction mammaplasty affected macromastia patients' depression, anxiety, and self-esteem (Saariniemi, 2009). Eighty-two patients were randomised, 40 to have the operation, and 42 patients to conservative treatment. Both groups were followed for six months. The patients completed the RBDI questionnaire (Raitasalo's modification of the short form of the Beck Depression Inventory). Twenty-nine patients in the operated group and 35 patients in the conservative group completed the study. At the second examination, the patients who had been operated on, had significantly less depression (p less than 0.01) and better self-esteem (p=0.03) than the conservative group. The proportions of depressed (p less than 0.01) and anxious (p=0.04) patients were also smaller in the group who were operated on. There is significantly less depression and anxiety after reduction mammaplasty, and patients' self-esteem is restored.