Anthem Blue Cross Connecticut CG-SURG-71 Reduction Mammaplasty Form

This document addresses reduction mammaplasty (plastic surgery of the breast intended to reduce volume by excision of tissue and often to improve shape and position), and does not apply to reconstructive procedures performed after surgery for breast cancer or other clinical indications, including removal of implants.

Note: This document does not address gender affirming surgery or procedures. Criteria for gender affirming surgery or procedures are found in applicable guidelines used by the plan.

Note: For other information related to breast procedures refer to:

• ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities
• CG-SURG-88 Mastectomy for Gynecomastia
• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant functional impairment, AND the procedure can be reasonably expected to improve the functional impairment.

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those that are primarily intended to preserve or improve appearance.

Clinical Indications

Medically Necessary:

Reduction mammaplasty is considered medically necessary when either of the following criteria (I or II) are met:

1. Individuals meeting BOTH of the following criteria (A and B):
   1. Presence of one or more of the following:
      1. A cervical or thoracic pain syndrome (upper back and shoulder pain), in which interference with daily activities or work has been documented. The pain is clearly related to the excess weight of the breast tissue and there has been at least 3 months of adequate conservative treatment with one or more of the following: special support garments (for example, special support bras, bras with wide straps), NSAIDs, physical therapy, or similar modalities; or
      2. Submammary intertrigo that is refractory to conventional medications and measures used to treat intertrigo, or shoulder grooving with ulceration unresponsive to conventional therapy; or
      3. Thoracic outlet syndrome (to include ulnar paresthesias from breast size) that has not responded to at least 3 months of adequate conservative treatment.
         and
   2. The preoperative evaluation by the surgeon concludes that an appropriate amount of breast tissue, from at least one breast, will be removed, based upon body surface area or total mass to be removed and that there is a reasonable prognosis of symptomatic relief. The request for surgery must include: the individual’s height and weight; the size and shape of the breast(s) causing symptoms; the anticipated amount of breast tissue to be removed. Pictures may be requested to document medical necessity.

Note: Medical records from the primary care physician and other providers (for example, physiatrist, orthopedic surgeon, etc.) who have diagnosed or treated the symptoms prompting this request may also be required.

The appropriate amounts (in grams) of breast tissue must be anticipated for removal from at least one breast, which is based on the individual’s total body surface area (BSA) in meters squared. See Appendix for a table relating BSA values to the minimum amount (weight) of breast tissue to be removed per breast.

Note: To calculate body surface area see: https://www.calculator.net/body-surface-area-calculator.html. Please use the Du Bois formula, with BSA represented in meters squared.

or

2. Individuals, regardless of BSA, who are anticipated to have at least 1 kg. of breast tissue removed from each breast and who meet the following criteria:
   1. Presence of one or more of the following :
      1. A cervical or thoracic pain syndrome (upper back and shoulder pain), in which interference with daily activities or work has been documented. The pain is clearly related to the excess weight of the breast tissue and there has been at least 3 months of adequate conservative treatment with one or more of the following: special support garments (for example, special support bras, bras with wide straps), NSAIDs, physical therapy, or similar modalities; or
      2. Submammary intertrigo that is refractory to conventional medications and measures used to treat intertrigo, or shoulder grooving with ulceration unresponsive to conventional therapy; or
      3. Thoracic outlet syndrome (to include ulnar paresthesias from breast size) that has not responded to at least 3 months of adequate conservative treatment.

Note: Medical records from the primary care physician and other providers (for example, physiatrist, orthopedic surgeon, etc.) who have diagnosed or treated the symptoms prompting this request may also be required.

Not Medically Necessary:

Breast reduction surgery is considered not medically necessary when the criteria above are not met including for breast cancer risk reduction.

The use of liposuction to perform breast reduction is considered not medically necessary.

Cosmetic and Not Medically Necessary:

Breast reduction surgery is considered cosmetic and not medically necessary for the following conditions: poor posture, breast asymmetry, pendulousness, problems with clothes fitting properly and nipple-areola distortion.