Breast Reduction Surgery Form

MEDICAL COVERAGE POLICY SERVICE: Breast Reduction Surgery Policy Number: 209 Effective Date: 02/01/2025 Last Review: 01/22/2026 Next Review: 01/22/2027 Page 1 of 5 Important note: Unless otherwise indicated, medical policies will apply to all lines of business. Medical necessity as defined by this policy does not ensure the benefit is covered. This medical policy does not replace existing federal or state rules and regulations for the applicable service or supply. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan documents. See the member plan specific benefit plan document for a complete description of plan benefits, exclusions, limitations, and conditions of coverage. In the event of a discrepancy, the plan document always supersedes the information in this policy. SERVICE: Breast Reduction Surgery PRIOR AUTHORIZATION: Required. POLICY: Please review the plan’s EOC (Evidence of Coverage) or Summary Plan Description (SPD) for details. Plans may exclude coverage for this therapy. Note: Unless otherwise indicated (see below), this policy will apply to all lines of business. For Medicare plans, please refer to appropriate Medicare NCD (National Coverage Determination) or LCD (Local Coverage Determination) L35090 Cosmetic and Reconstructive Surgery. If there are no applicable NCD or LCD criteria, use the criteria set forth below. For Medicaid plans, please confirm coverage as outlined in the Texas Medicaid Provider Procedures Manual | TMHP (TMPPM). If there are no applicable criteria to guide medical necessity decision making in the TMPPM, use the criteria set forth below. BSWHP may consider breast reduction surgery medically necessary for non-cosmetic indications for women that have significantly enlarged breasts that meet the following criteria:

1. Age ≥ 18 OR for whom growth is complete (i.e., breast size stable over one year), AND
2. Photo documentation of macromastia, AND
3. Presence of at least TWO of the following signs and/or symptoms present for at least 6 months: a. Back pain, neck pain, or shoulder pain from macromastia, unrelieved by at least 6 weeks of:  Conservative analgesia
    Supportive measures (garment, etc.)  Physical therapy b. Significant arthritic changes in the cervical or upper thoracic spine, with persistent symptoms despite optimal management and/or restriction of activity. c. Intertriginous maceration or infection of the inframammary skin refractory to dermatologic treatment measures. d. Shoulder grooving with skin irritation by supporting garment (bra strap). e. Upper extremity neuropathy secondary to macromastia (other etiologies excluded)
4. AND, macromastia is not due to an active endocrine, pharmaceutical, or metabolic process.
5. AND, breast cancer screening / testing has been completed when appropriate (family history of breast cancer, age, etc.)
6. AND, excess breast tissue to be removed (estimated amount) falls under the following parameters: a. 199 grams to 238 grams per breast and Body Surface Area (BSA) 1.35 to 1.45

MEDICAL COVERAGE POLICY SERVICE: Breast Reduction Surgery Policy Number: 209 Effective Date: 02/01/2025 Last Review: 01/22/2026 Next Review: 01/22/2027 Page 2 of 5 b. 239 grams to 284 grams per breast and Body Surface Area (BSA) 1.46 to 1.55 c. 285 grams to 349 grams per breast and Body Surface Area (BSA) 1.56 to 1.69 d. ≥ 350 grams per breast Exclusions:

1. Suction lipectomy or ultrasonically-assisted suction lipectomies (liposuction) are not considered medically necessary as they are experimental and investigational.
2. Cosmetic surgery to reshape the breasts to improve appearance is not a covered benefit. Cosmetic signs and/or symptoms would include ptosis, poorly fitting clothing and beneficiary perception of unacceptable appearance. BACKGROUND: Macromastia (breast hypertrophy) is an increase in the volume and weight of breast tissue relative to the general body habitus. Breast hypertrophy may adversely affect other body systems (e.g., musculoskeletal, respiratory, integumentary). Unilateral hypertrophy may result in symptoms following contralateral mastectomy.
   Reduction mammoplasty is sometimes performed:  To reduce the size of the breasts and help ameliorate symptoms caused by hypertrophy.  To reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery.  When the signs and/or symptoms resulting from the enlarged breasts (macromastia) have not responded adequately to non-surgical interventions. Non-surgical interventions preceding reduction mammoplasty should include as appropriate, but are not limited to, the following:  Determining the macromastia is not due to an active endocrine or metabolic process.  Determining the symptoms are refractory to appropriately fitted supporting garments, or following unilateral mastectomy, persistent with an appropriately fitted prosthesis or reconstruction therapy at the site of an absent breast.  Determining that dermatologic signs and/or symptoms are refractory to or recurrent following a completed course of medical management. Current smokers and patients with BMI > 40 are at significantly increased risk of reduction mammoplasty complications. MANDATES:
   Under Women’s Health and Cancer Rights Act (WHCRA) of 1998, group health plans, insurance companies and health maintenance organizations offering mastectomy coverage also must provide

MEDICAL COVERAGE POLICY SERVICE: Breast Reduction Surgery Policy Number: 209 Effective Date: 02/01/2025 Last Review: 01/22/2026 Next Review: 01/22/2027 Page 3 of 5 coverage for certain services relating to the mastectomy in a manner determined in consultation with the member and his/her attending physician, whether or not the mastectomy was covered by BSWHP.
Required coverage includes:  All stages of reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance;  Prostheses; and  Treatment of physical complications of the mastectomy, including lymphedema.
Nothing in the law limits WHCRA rights to women or cancer patients. CODES: Important note: CODES: Due to the wide range of applicable diagnosis codes and potential changes to codes, an inclusive list may not be presented, but the following codes may apply. Inclusion of a code in this section does not guarantee that it will be reimbursed, and patient must meet the criteria set forth in the policy language. CPT Codes: 19318 - Reduction of large breast ICD10 Codes: N62 - Hypertrophy of breast (Required) Plus one of the following: N65.1 - Disproportion of reconstructed breast L30.4 - Erythema intertrigo M25.511 - Pain in right shoulder M25.512 - Pain in left shoulder M25.519 - Pain in unspecified shoulder M54.2 - Cervicalgia M54.6 - Pain in thoracic spine R21 - Rash and other nonspecific skin eruption POLICY HISTORY: Status Date Action New 02/14/2014 New policy Review 02/12/2015 Reviewed Update 11/17/2015 Added supporting data Review 02/04/2016 No material change Review 01/31/2017 Added smoking & BMI criteria and suction lipectomy exclusion. References updated. Review 01/16/2018 No changes Review 01/08/2019 No changes Review 01/23/2020 No changes Updated 05/28/2020 Reviewed and aligned for FirstCare and SWHP

MEDICAL COVERAGE POLICY SERVICE: Breast Reduction Surgery Policy Number: 209 Effective Date: 02/01/2025 Last Review: 01/22/2026 Next Review: 01/22/2027 Page 4 of 5 Review 05/27/2021 No changes Review 05/26/2022 Minor cosmetic changes Review 05/25/2023 No changes Review 05/13/2024 Formatting changes and added hyperlinks to CMS and TMPPM resources, beginning and ending note sections updated to align with CMS requirements and business entity changes. Updated 01/13/2025 Updated Breast Reduction Surgery Medical Necessity criteria. Ending note section updated to align with business entity changes. Updated 08/11/2025 Removed “Medicare NCD or LCD specific InterQual criteria may be used when available.” Reviewed 01/22/2026 Removed BMI and smoking requirement. REFERENCES: The following scientific references were utilized in the formulation of this medical policy. BSWHP will continue to review clinical evidence related to this policy and may modify it at a later date based upon the evolution of the published clinical evidence. Should additional scientific studies become available, and they are not included in the list, please forward the reference(s) to BSWHP so the information can be reviewed by the Medical Coverage Policy Committee (MCPC) and the Quality Improvement Committee (QIC) to determine if a modification of the policy is in order.

1. Blomqvist L, Eriksson A, Brandberg Y. Reduction Mammaplasty Provides Long-Term Improvement in Health Status and Quality of Life. Plast. Reconstr. Surg. 106:991, 2000.
2. Thoma A, Sprague S, Veltri K, Duku E, Furlong W. A Prospective Study of Patients Undergoing Breast Reduction Surgery: Health-Related Quality of Life and Clinical Outcomes Plast. Reconstr. Surg. 120:13, 2007.
3. Collins ED, Kerrigan CL, Kim M, Lowery JC, Striplin DT Cunningham B, Wilkins EG. The Effectiveness of Surgical and NonSurgical Interventions in Relieving the Symptoms of Macromastia. Plast. Reconstr. Surg. 109:1556, 2002.
4. Nahai FR, Nahai F. Breast Reduction. Plast. Reconstr. Surg. 121: 1, 2008.
5. R. Barrett Noone, An Evidence-Based Approach to Reduction Mammaplasty. Plast. Reconstr. Surg. 126:2171, 2010.
6. Kalliainen L, ASPS Health Policy Committee. ASPS Clinical Practice Guideline Summary on Reduction Mammaplasty. Plast. Reconstr. Surg. 130:785, 2012.
7. Kerrigan, CL, Slezak, S. Evidence-Based Medicine: Reduction Mammaplasty. Plast. Reconstr. Surg. 132:1670, 2013.
8. Saariniemi KM, Sintonen H, Kuokkanen HO. The improvement in quality of life after breast reduction is comparable to that after major joint replacement. Scand J Plast Reconstr Surg Hand Surg. 2008;42(4):194-8.
9. Nelson JA, Fischer JP, Chung CU, West A, Tuggle CT, Serletti JM, Kovach SJ. Obesity and early complications following reduction mammaplasty: an analysis of 4545 patients from the 2005-2011 NSQIP datasets. J Plast Surg Hand Surg. 2014 Oct;48(5):334-9.
10. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. Tobacco Use and Body Mass Index as Predictors of Outcomes in Patients Undergoing Breast Reduction Mammoplasty. Ann Plast Surg. 2015 Oct;75(4):383-7.
11. Schnur, Paul L. et al., “Reduction Mammoplasty: Cosmetic or Reconstructive Procedure? Annals of Plastic Surgery. Sept 1991: 27 (3): 232-237.
12. Hansen J, Chang S. Overview of Breast Reduction. UpToDate, Collins KA (Ed), Wolters Kluwer. (Accessed 1/3/2025).

MEDICAL COVERAGE POLICY SERVICE: Breast Reduction Surgery Policy Number: 209 Effective Date: 02/01/2025 Last Review: 01/22/2026 Next Review: 01/22/2027 Page 5 of 5 Note: Health Maintenance Organization (HMO) products are offered through Scott and White Health Plan dba Baylor Scott & White Health Plan, and Scott & White Care Plans dba Baylor Scott & White Care Plan. Insured PPO and EPO products are offered through Baylor Scott & White Insurance Company. Scott and White Health Plan dba Baylor Scott & White Health Plan serves as a third-party administrator for self-funded employer-sponsored plans. Baylor Scott & White Care Plan and Baylor Scott & White Insurance Company are wholly owned subsidiaries of Scott and White Health Plan. These companies are referred to collectively in this document as Baylor Scott & White Health Plan. RightCare STAR Medicaid is offered through Scott and White Health Plan in the Central Texas Medicaid Rural Service Area (MRSA); FirstCare STAR is offered through SHA LLC dba FirstCare Health Plans (FirstCare) in the Lubbock and West MRSAs; and FirstCare CHIP is offered through FirstCare in the Lubbock Service Area.