Latest Review Date: February 2024

Category: Surgery    

POLICY:

Reduction mammaplasty may be considered medically necessary for patients aged 18 or older or for adolescents whose breasts are fully developed; i.e., patient has maintained current height, weight, and breast size for 12 months, when:

• a minimum of 500 grams of breast tissue is to be removed from each breast; OR

• a combined minimum total of 1000 grams of breast tissue is to be removed from both breasts; OR

• a patient is of small stature (5 feet 3 inches and under), consideration will be given for removal of less than 500 grams of breast tissue from each breast using the Schnur Sliding Scale chart.  Body surface area is calculated and then the Schnur Sliding Scale chart is used to determine the number of grams to be removed from each breast. (See www-users.med.cornell.edu/~spon/picu/calc/bsacalc.htm )

And two or more of the following medical indications are met:

• Pain in the upper back and shoulders resulting in documented treatment and interference with activities of daily living.  This pain should be evaluated to determine that it is not associated with another diagnosis such as arthritis.  The pain is not relieved by conservative therapy. Examples include but are not limited to: including an appropriate support bra, exercises, heat/cold treatments and appropriate non-steroidal anti-inflammatory agents/muscle relaxants.

• Dermatitis of skin of shoulder or shoulder grooving not responding to conservative treatment, including support bra.

• Intertrigo between the pendulous breast and the chest wall

• Sternal notch to nipple measurements of 26cm or greater

To ensure the above criteria are met, the patient’s medical records must contain frontal and lateral view photographs, patient’s height and weight, amount of breast tissue removed documented by pathology report, documentation of the size and shape of the breast causing symptomology, and documentation of patient’s symptomology for 6 months prior to procedure.

Liposuction as a sole procedure for reduction mammaplasty is considered investigational. Liposuction may be used as an adjunct procedure to the surgical procedure of reduction mammaplasty.

Reduction mammaplasty is considered investigational for all other indications not meeting the above criteria.

Reduction mammaplasty performed post-mastectomy for cancer, on the contralateral breast to match the prosthesis size, is not required to meet the criteria for reduction mammaplasty.

DESCRIPTION OF PROCEDURE OR SERVICE:

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. In addition, macromastia may be associated with psychosocial or emotional disturbances related to the large breast size.

Reduction mammaplasty (breast reduction) is a surgical excision of a substantial portion of breast tissue that includes the skin and underlying glandular tissue.  Reduction mammaplasty may reduce the size, change the shape, and/or lift the breast tissue.

The Schnur Sliding Scale Chart

_{BSA (m²) = ([height (in) x weight (lb)]/3131)^½}

_{BSA (m²) = ([height (cm) x weight (kg)]/3600)^½}

KEY POINTS:

This review has been updated regularly with searches of the PubMed database. The most recent literature review was performed through December 20, 2023. The following is a summary of the key findings to date.

Summary of Evidence

The evidence for reduction mammaplasty in individuals who have symptomatic macromastia includes randomized controlled trials and case series. Relevant outcomes are symptoms and functional outcomes. These studies indicate that reduction mammaplasty is effective at decreasing breast-related symptoms such as pain and discomfort. There is also evidence that functional limitations related to breast hypertrophy are improved following reduction mammaplasty. These outcomes are achieved with acceptable complication rates. Overall, reduction mammaplasty in appropriately selected patients is associated with improvements in several important health outcomes.

Practice Guidelines and Position Statements

American Society of Plastic Surgeons

In 2011, the American Society of Plastic Surgeons (ASPS) issued practice guidelines and a companion document on criteria for third-party payers for reduction mammaplasty. This guideline was updated and reaffirmed in March 2021. Based on high quality evidence, the ASPS strongly recommends that "postmenarche female patients presenting with breast hypertrophy should be offered reduction mammaplasty surgery as first-line therapy over nonoperative therapy based solely on the presence of multiple symptoms rather than resection weight." The guideline goes on to state that "reduction mammaplasty surgery is considered standard of care for symptomatic breast hypertrophy." The companion document notes that medical records should document the symptoms associated with the hypertrophy the patient has experienced, and lists the following:

• "Documentation may include pain that patient experiences in the neck, back, or breasts related to movement
• Difficulties in daily activities such as grocery shopping, banking, using transportation, preparing meals, feeding, showering, etc
• Documentation of any secondary complications or infections that may have occurred as a result of hypertrophy or macromastia including intertrigo, chronic rash, cervicalgia, dorsalgia, or kyphosis
• Documentation of prior procedures or therapies may be included but not required for approval
• Photographs demonstrating the patient’s breast appearance, possible shoulder grooves and kyphosis can be included in the medical documentation
• Significant scientific evidence supports non-operative therapies should not be required prior to approval of the procedure."

U.S. Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

Reduction mammoplasty, breast reduction, liposuction, reduction mammaplasty, macromastia, gigantomastia

APPROVED BY GOVERNING BODIES:

Surgical procedures are not regulated by the U.S. Food and Drug Administration

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP: Special benefit consideration may apply.  Refer to member’s benefit plan. 

CURRENT CODING: 

CPT code:

REFERENCES:

1. American Society of Plastic Surgeons. Evidence-based Clinical Practice Guideline: Reduction Mammaplasty. www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Reduction_Mammaplasty_Evidence_Based_Guideline%20%282%29%282%29.pdf.
2. American Society of Plastic Surgeons. Reduction Mammaplasty: ASPS Recommended Insurance Coverage Criteria for Third-Party Payers. 2021; www.plasticsurgery.org/documents/Health-Policy/Reimbursement/insurance-2021-reduction-mammaplasty.pdf.
3. Anzarut A, Guenther CR, Edwards DC and Tsuyuki RT. Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. Plast Reconstr Surg, April 2007; 119(4): 1159-1166.
4. Chen CL, Shore AD, Johns R et al. The impact of obesity on breast surgery complications. Plast Reconstr Surg Nov 2011; 128(5):395e-402e.
5. Collins ED, Kerrigan CL, Kim M, et al. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plast Reconstr Surg. Apr 15 2002; 109(5):1556-1566.
6. Dabbah A, Lehman JA, Jr., Parker MG, et al. Reduction mammaplasty: an outcome analysis. Ann Plast Surg. Oct 1995; 35(4):337-341.
7. Glatt BS, Sarwer DB, O'Hara DE, et al. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Plast Reconstr Surg. Jan 1999; 103(1):76-82; discussion 83-75.
8. Gray, L.N.  Liposuction breast reduction, Aesth Plast Surg 1998; 22:159-162.
9. Gray, Lawrence N.  Update on experience with liposuction breast reduction, Atlantic Plastic Surgery Center, September 2001, Vol. 8, No. 4, pp. 1006-1010.
10. Gust MJ, Smetona JT, Persing JS, et al. 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.
11. Hernanz F, Fidalgo M, Munoz P, et al. Impact of reduction mammaplasty 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.
12. Hidalgo, M.D., David A., Franklyn, M.D., Elliot L., et al. Current trends in breast reduction, Plast Reconstr Surg, September 1999, Vol. 104(3), 806-815; quiz 816; discussion 817-818.
13. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
14. Iwuagwu OC, Platt AJ, Stanley PW, et al. Does reduction mammaplasty improve lung function test in women with macromastia? Results of a randomized controlled trial. Plast Reconstr Surg. Jul 2006; 118(1):1-6; discussion 7.
15. Iwuagwu OC, Walker LG, Stanley PW, et al. Randomized clinical trial examining psychosocial and quality of life benefits of bilateral breast reduction surgery. Br J Surg. Mar 2006; 93(3):291-294.
16. Kalliainen LK. ASPS Clinical Practice Guideline Summary on Reduction Mammaplasty. Plast Reconstr Surg. Oct 2012; 130(4):785-789.
17. Kerrigan CL, Collins ED, Kim HM, et al. Reduction mammaplasty: defining medical necessity. Med Decis Making. May-Jun 2002; 22(3):208-217.
18. Matarasso, A.  Suction mammaplasty:  The use of suction lipectomy to reduce large breasts, Plast Reconstr Surg 2000; 105(7): 2604-2607.
19. Myung Y, Heo CY. Relationship Between Obesity and Surgical Complications After Reduction Mammaplasty: A Systematic Literature Review and Meta-Analysis. Aesthet Surg J. Mar 1 2017; 37(3):308-315.
20. Nelson JA, Fischer JP, Chung CU, et al. 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.
21. Perdikis G, Dillingham C, Boukovalas S, et al. American Society of Plastic Surgeons Evidence-Based Clinical Practice Guideline Revision: Reduction Mammaplasty. Plast Reconstr Surg. Mar 01 2022; 149(3): 392e-409e.
22. Saariniemi KM, Keranen UH, Salminen-Peltola PK, et al. Reduction mammaplasty is effective treatment according to two quality of life instruments. A prospective randomised clinical trial. J Plast Reconstr Aesthet Surg. Dec 2008; 61(12):1472-1478.
23. Sabino Neto M, Dematte MF, Freire M, et al. Self-esteem and functional capacity outcomes following reduction mammaplasty. Aesthet Surg J. Jul-Aug 2008; 28(4):417-420.
24. Schnur, Paul, et al.  Reduction mammaplasty:  Cosmetic or reconstructive procedure? Annals of Plastic Surgery, Sep 1991; 27(3); 232-237.
25. Schnur PL. Reduction mammaplasty-the schnur sliding scale revisited. Ann Plast Surg. Jan 1999; 42(1):107-108.
26. Schnur PL, Schnur DP, Petty PM, et al. Reduction mammaplasty: an outcome study. Plast Reconstr Surg. Sep 1997; 100(4):875-883.
27. Shermak MA, Chang D, Buretta K et al. Increasing age impairs outcomes in breast reduction surgery. Plast Reconstr Surg Dec 2011; 128(6):1182-1187.
28. Singh KA, Losken A. Additional benefits of reduction mammaplasty: a systematic review of the literature. Plast Reconstr Surg Mar 2012; 129(3):562-570.
29. Thibaudeau S, Sinno H, Williams B. The effects of breast reduction on successful breastfeeding: a systematic review. J Plast Reconstr Aesthet Surg Oct 2010; 63(10):1688-1693.
30. Torresetti M, Zuccatosta L, Di Benedetto G. The effects of breast reduction on pulmonary functions: A systematic review. JPlast Reconstr Aesthet Surg. Dec 2022; 75(12): 4335-4346.

POLICY HISTORY:

Medical Policy Group, July 2002

Medical Policy Administration Committee, July 2002

Available for comment July 19-September 3, 2002

Medical Policy Administration Committee, October 2002

Available for comment October 29-December 12, 2002

Medical Policy Group, January 2004

Medical Policy Group, June 2005 (3)

Medical Policy Group, January 2006 (1)

Medical Policy Group, July 2007 (1)

Medical Policy Group, February 2009 (1)

Medical Policy Group, May 2010 (1)

Medical Policy Group, November 2011 (1) Update to Key Points; no change in policy statement

Medical Policy Group; October 2012 (1) Update to Policy, and Key Points related to addition of coverage criteria of combined minimum total of 1000 grams of breast tissue removed from both breasts

Medical Policy Administration Committee, October 2012

Available for comment October 24 through December 10, 2012

Medical Policy Group, July 2013 (1) Update to Key Points and References; no change in policy statement

Medical Policy Group, November 2013 (1) Policy reviewed with literature search, policy statement unchanged, no references added

Medical Policy Panel, November 2014

Medical Policy Group, February 2015 (3): Updates to Description, Key Points, Key Words, Approved Governing Bodies, and References.  Added Policy statement to include “all other indications not meeting the above criteria” is investigational.  Policy intent unchanged.

Medical Policy Group, November 2015 (1) added the word “female” before word ”adolescents” in the criteria section for clarification; policy intent unchanged.

Medical Policy Panel, February 2016

Medical Policy Group, February 2016 (2): 2016 Updates to Key Points and References; no change in policy statement.

Medical Policy Panel, February 2017

Medical Policy Group, March 2017 (7): 2017 Updates to Key Points and References. No change to policy statement.

Medical Policy Panel, February 2018

Medical Policy Group, February 2018 (7): 2018 Updates to Key Points and References. No change to policy statement.

Medical Policy Panel, February 2019

Medical Policy Group, April 2019 (7): Updates to Key Points. No new literature to add. No change to policy statement.

Medical Policy Panel, February 2020

Medical Policy Group, March 2020 (7): Updates to Key Points. No new literature to add. No change to policy statement.

Medical Policy Group, October 2020: 2021 Annual Coding Update. Revised description of CPT 19318 to state “breast reduction”.

Medical Policy Panel, February 2021

Medical Policy Group, February 2021 (7): Minor updates to Key Points. No new literature to add. No change to policy statement.

Medical Policy Group, August 2021 (7): Removed "not medically necessary" statements from Policy Statement. No change in intent.

Medical Policy Group, February 2022 (7): Minor updates to Key Points. No new literature to add. No change to policy statement.

Medical Policy Panel, February 2023

Medical Policy Group, February 2023 (7): Updates to Key Points, Benefit Application, and References. No change to policy statement.

Medical Policy Group, May 2023 (7): Clarification to conservative therapy examples in Policy Statement. Added “Examples include but are not limited to.”  No change to policy intent.

Medical Policy Panel, February 2024

Medical Policy Group, February 2024 (7): Updates to Key Points, Benefit Application, and References. No change to policy statement.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.