Reduction Mammaplasty (Non-Cancerous) (Reduction Mammoplasty)
DESCRIPTION
Reduction mammoplasty is a surgical procedure designed to remove a variable proportion of breast tissue. Macromastia, or gigantomastia, is a condition that describes breast hyperplasia or hypertrophy and 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. The available evidence from randomized controlled and prospective studies indicates that reduction mammoplasty 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 mammoplasty.
POLICY
Reduction mammoplasty is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Reduction mammoplasty for the treatment of other conditions/diseases is considered cosmetic.
MEDICAL APPROPRIATENESS
Reduction mammoplasty is considered medically appropriate if ALL of the following are met:
Diagnosis of macromastia
Age is ANY ONE of the following:
Age eighteen (18) or older
Adolescent under age eighteen (18) has reached breast maturity
Adolescent under age eighteen (18) has had stability in cup size for over six (6) months
Documentation of ANY ONE of the following:
Individual age 40 or older with negative mammogram (for cancer) within one year prior to date of planned reduction mammoplasty
Individual under age 40 with no evidence of breast cancer (determined by attending physician)
Symptoms of breast hypertrophy as indicated by 2 or more of the following:
Backache
Neck pain
Shoulder pain
Upper extremity peripheral neuropathy
Postural change with a tendency toward dorsal kyphosis
Problems associated with breast weight and brassiere support, such as clavicular bra strap grooves
Hygiene problems, such as intertrigo or exacerbation of acne and hidradenitis suppurativa
Limitations of normal activity, such as inability to participate in exercise and sports
Difficulty sleeping or breathing due to weight of the breasts
Failure to relieve symptoms with nonsurgical treatment that includes a six week history of ANY ONE of the following:
Appropriate support bra
Exercises
Heat/cold treatment
Nonsteroidal anti-inflammatory agents/muscle relaxants
Estimated tissue removal of ANY ONE of the following:
A minimum of 500 grams of breast tissue estimated to be removed from each breast
Less than 500 grams of breast tissue estimated to be removed when ALL of the following are met:
Individual is of small stature (5’ 3” and under)
Estimated grams of breast tissue for removal per breast falls above the 22nd percentile on Schnur Sliding Scale relative to body surface area.
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
SOURCES
American College of Obstetricians and Gynecologists. (2017, January; Reaffirmed 2020). Committee opinion: Breast and labial surgery in adolescents. Retrieved May 3, 2021 from https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Breast-and-Labial-Surgery-in-Adolescents.
American Society of Breast Surgeons Foundation. (2018). Breast reduction/reduction mammaplasty. Retrieved April 25, 2018 from https://breast360.org/en/topics/2015/01/01/breast-reduction-reduction-mammaplasty/.
American Society of Plastic Surgeons. (2021, March). Recommended insurance coverage criteria for third-party payers: reduction mammaplasty. Retrieved June 30, 2023 from https://www.plasticsurgery.org/documents/health-policy/reimbursement/insurance-2021-reduction-mammaplasty.pdf.
American Society of Plastic Surgeons. (2022). Evidence-based clinical practice guideline revision: reduction mammoplasty. Retrieved June 30, 2023 from https://www.plasticsurgery.org/for-medical-professionals/quality/evidence-based-clinical-practice-guidelines.
BlueCross BlueShield Association. Evidence Positioning System. (3:2023). Reduction mammoplasty for breast-related symptoms (7.01.21). Retrieved June 29, 2023 from https://www.evidencepositioningsystem.com/. (22 articles and/or guidelines reviewed)
British Association of Plastic Reconstructive and Aesthetic Surgeons. (May, 2014). Commissioning guide: breast reduction surgery. Retrieved May 18, 2015 from http://www.rcseng.ac.uk.
Cerrato, F., Webb, M., Rosen, H., Nuzzi, L., McCarty, E., DiVasta, A., et al. (2012). The impact of macromastia on adolescents: a cross-sectional study. Pediatrics, 130 (2), e339-e446. (Level 3 evidence)
CMS.gov: Centers for Medicare & Medicaid Services. Palmetto GBA. (2021, July). Cosmetic and reconstructive surgery. (LCD ID L33428). Retrieved April 18, 2022 from http://www.cms.gov.
Hudson, A., Morzycki, A., & Guilfoyle, R. (2021). Reduction mammaplasty for macromastia in adolescents: a systematic review and pooled analysis. Plastic and Reconstructive Surgery, 148 (1), 31–43. Abstract retrieved June 30, 2023 from PubMed database.
Manahan, M.A., Buretta, K.J., Chang, D., Mithani, S.K., Mallalieu, J., & Shermak, M.A. (2015). An outcomes analysis of 2142 breast reduction procedures. Annals of Plastic Surgery, 74 (3), 289-292. Abstract retrieved June 3, 2015 from PubMed database.
National Comprehensive Cancer Network. (2023, June). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Breast cancer screening and diagnosis. Retrieved June 29, 2023 from the National Comprehensive Cancer Network.
Nelson, J.A., Fischer, J.P., Chung, C.U., West, A., Tuggle, C.T., et al. (2014). Obesity and early complications following reduction mammaplasty: an analysis of 4545 patients from the 2005-2011 NSQIP datasets. Journal of Plastic Surgery and Hand Surgery, 48 (5), 334-339. Abstract retrieved July 24, 2015 from PubMed database.
Strong, B. & Hall-Findlay, E. (2014). How does volume of resection relate to symptom relief for reduction mammaplasty patients? Annals of Plastic Surgery, 75 (4), 376-382. Abstract retrieved June 7, 2016 from PubMed database.
ORIGINAL EFFECTIVE DATE: 1/1/1997
MOST RECENT REVIEW DATE: 8/10/2023
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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