703 Form

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Medical Policy Reduction Mammaplasty for Breast-Related Symptoms Table of Contents • Policy: Commercial • Description • Information Pertaining to All Policies
• Authorization Information • Policy History • Endnotes • Coding Information • References

Policy Number: 703 BCBSA Reference Number: 7.01.21 (For Plan internal use only) Related Policies
Surgical Treatment of Gynecomastia, #661

Policy1 Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Reduction mammoplasty may be considered MEDICALLY NECESSARY for the treatment of macromastia when the following well-documented clinical symptoms are present AND if a member is under age 18, the following age criteria must also be met:

Age Criteria: • Documented tanner stage IV or V for members aged 15-18, AND • Stable height measurements for 6 months, OR • Puberty completion as shown on wrist radiograph.

Clinical Symptoms: • Documentation of a minimum 6-week history of shoulder, neck, or back pain related to macromastia that is not responsive to conservative therapy, such as an appropriate support bra, exercises, heat/cold treatment, and appropriate nonsteroidal anti-inflammatory agents/muscle relaxants. This includes documentation of the presence of shoulder grooving, an indication that the breast weight results in grooving of the bra straps on the shoulder, OR
• Recurrent or chronic intertrigo between the pendulous breast and the chest wall that is resistant to topical treatment.

Individuals meeting the above criteria should have either a minimum of 350g per breast removed OR the surgeon should follow the below Schnur sliding scale, which suggests a minimum amount of breast tissue removed based on a patient’s body surface area if the planned weight to be resected from each breast falls below 350g.

2 Body Surface Area (m2) and Weight of Breast Tissue Removed [per breast] Body Surface Area (m2) Minimum Grams of Breast Tissue to be Removed 1.35 199 1.40 218 1.45 238 1.50 260 1.55 284 1.60 310 1.65 338 1.69 349 Calculation of Body Surface Area (BSA) • Mosteller formula: Body surface area = the square root of height (cm) multiplied by weight (kg) divided by 3,600.
• To convert pounds to kilograms, multiply pounds by 0.45
• To convert inches to meters, multiply inches by 0.0254

Click the hyperlink for an online BSA calculator:
https://reference.medscape.com/calculator/28/bmi-and-bsa-mosteller

Note: The scale above is taken from the Schnur Sliding Scale and shows the BSA and associated grams of breast tissue to be removed to meet the 22nd percentile where women are likely to have a reduction mammoplasty primarily for medical reasons.

Repeat reduction mammaplasty may be considered MEDICALLY NECESSARY if • there are complications resulting from the initial surgery, OR • the member meets the same criteria for reduction mammaplasty that were required for the original surgery’s approval including the following: o BMI must be less than 35, AND o No evidence of Body Dysmorphic Disorder.

Reduction mammoplasty is considered INVESTIGATIONAL for all other indications not meeting the
above criteria.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is required. Commercial
Prior authorization is required.

3 Requesting Prior Authorization Using Authorization Manager Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.
To ensure the service request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources Refer to our Authorization Manager page for tips, guides, and video demonstrations.

CPT Codes / HCPCS Codes / ICD Codes
Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity: CPT Codes CPT codes: Code Description 19318 Breast reduction ICD-10 Procedure Codes ICD-10-PCS procedure codes: Code Description 0HBT0ZZ Excision of Right Breast, Open Approach 0HBT3ZZ Excision of Right Breast, Percutaneous Approach 0HBU0ZZ Excision of Left Breast, Open Approach 0HBU3ZZ Excision of Left Breast, Percutaneous Approach 0HBV0ZZ Excision of Bilateral Breast, Open Approach 0HBV3ZZ Excision of Bilateral Breast, Percutaneous Approach

Description Macromastia 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. Also, macromastia may be associated with psychosocial or emotional disturbances related to the large breast size.

4 Treatment Reduction mammaplasty is a surgical procedure designed to remove a variable proportion of breast tissue to address emotional and psychosocial issues and/or to relieve the associated clinical symptoms. While literature searches have identified many articles that discuss the surgical technique of reduction mammaplasty and have documented that reduction mammaplasty is associated with relief of physical and psychosocial symptoms,1,2,3,4,5,6,7,8,9, an important issue is whether reduction mammaplasty is a functional need or cosmetic. For some patients, the presence of medical indications is clear- cut: clear documentation of recurrent intertrigo or ulceration secondary to shoulder grooving. For some patients, the documentation differentiating between a cosmetic and a medically necessary procedure will be unclear. Criteria for medically necessary reduction mammaplasty are not well-addressed in the published medical literature. Some protocols on the medical necessity of reduction mammaplasty are based on the weight of removed breast tissue. The basis of weight criteria is not related to the outcomes of surgery, but to surgeons retrospectively classifying cases as cosmetic or medically necessary. Schnur et al. (1991) at the request of third-party payers, developed a sliding scale.10, This scale was based on survey responses from 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 they had performed. Surgeons were also asked if the procedures 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 that differentiated cosmetic and medically necessary procedures. Based on their estimates, those with a breast tissue removed weight above the twenty-second percentile likely had the procedure for medical reasons, while those below the fifth percentile likely had the procedure performed for cosmetic reasons; those falling between the cutpoints had the procedure performed for mixed reasons. Schnur (1999) reviewed the use of the sliding scale as a coverage criterion and reported that, while many payers had adopted it, many had also misused it.11, Schnur pointed out that if a payer used weight of resected tissue as a coverage criterion, then if the weight fell below the fifth percentile, the reduction mammaplasty would be considered cosmetic; if above the twenty-second percentile, it would be considered medically necessary; and if between these cutpoints, it would be considered on a case-by- case basis. Schnur also questioned the frequent requirement that a woman is within 20% of her ideal body weight. While weight loss might relieve symptoms, durable weight loss is notoriously difficult and might be unrealistic in many cases. Summary
Description 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 is a surgical procedure designed to remove a variable proportion of breast tissue to address emotional and psychosocial issues and/or to relieve the associated clinical symptoms. Summary of Evidence For individuals who have symptomatic macromastia who receive reduction mammaplasty, the evidence includes systematic reviews of randomized controlled trials, cohort studies, and case series. Relevant outcomes are symptoms and functional outcomes. Studies have indicated 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 after reduction mammaplasty. These outcomes are achieved with acceptable complication rates. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

5 Policy History Date Action 4/2026 Annual policy review. Policy updated with literature review through December 23, 2025; no references added. Policy statements unchanged. 4/2025 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 9/2023 Policy clarified to include prior authorization requests using Authorization Manager.
4/2023 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 6/2022 Prior authorization information clarified for PPO plans. Effective 6/1/2022. 3/2022 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 12/2021 Policy clarified. New medically necessary indications described for repeat reduction mammoplasty. 10/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 4/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 3/2021 Policy criteria on the minimum amount of breast tissue removal was revised from 500 grams to 350 grams. Effective 3/1/2021.
1/2021 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
4/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2020 Investigational statements on repeat reduction mammaplasty clarified. 11/2019 Policy clarified to indicate that repeat reduction mammaplasty is investigational.
4/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 4/2018 Reference list updated. Policy statements unchanged. 3/2017 Annual policy review. New references added. 7/2016 Medically necessary statement clarified. 3/2016 Annual policy review. New references added. 11/2015 Age minimum for breast reduction revised from 18 to 15 years old. Medically necessary guidelines revised to include evidence that puberty is complete for breast augmentation. Clarified coding information. Effective 11/1/2015. 1/2015 Annual policy review. Investigational language clarified. Effective 1/1/2015. 11/2014 Language transferred from medical policy #068, Plastic Surgery. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

6 References

1. Dabbah A, Lehman JA, Parker MG, et al. Reduction mammaplasty: an outcome analysis. Ann Plast Surg. Oct 1995; 35(4): 337-41. PMID 8585673
2. Schnur PL, Schnur DP, Petty PM, et al. Reduction mammaplasty: an outcome study. Plast Reconstr Surg. Sep 1997; 100(4): 875-83. PMID 9290655
3. Hidalgo DA, Elliot LF, Palumbo S, et al. Current trends in breast reduction. Plast Reconstr Surg. Sep 1999; 104(3): 806-15; quiz 816; discussion 817-8. PMID 10456536
4. 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 83-5. PMID 9915166
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): 1556-66. PMID 11932597
6. 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): 291-4. PMID 16363021
7. Sabino Neto M, Demattê MF, Freire M, et al. Self-esteem and functional capacity outcomes following reduction mammaplasty. Aesthet Surg J. 2008; 28(4): 417-20. PMID 19083555
8. 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. PMID 16816661
9. 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): 1472-8. PMID 17983882
10. Schnur PL, Hoehn JG, Ilstrup DM, et al. Reduction mammaplasty: cosmetic or reconstructive procedure?. Ann Plast Surg. Sep 1991; 27(3): 232-7. PMID 1952749
11. Schnur PL. Reduction mammaplasty-the schnur sliding scale revisited. Ann Plast Surg. Jan 1999; 42(1): 107-8. PMID 9972729
12. Lin Y, Yang Y, Zhang X, et al. Postoperative Health-related Quality of Life in Reduction Mammaplasty: A Systematic Review and Meta-Analysis. Ann Plast Surg. Jul 01 2021; 87(1): 107-
13. PMID 33346564
14. Beraldo FN, Veiga DF, Veiga-Filho J, et al. Sexual Function and Depression Outcomes Among Breast Hypertrophy Patients Undergoing Reduction Mammaplasty: A Randomized Controlled Trial. Ann Plast Surg. Apr 2016; 76(4): 379-82. PMID 25536204
15. Iwuagwu OC, Stanley PW, Platt AJ, et al. Effects of bilateral breast reduction on anxiety and depression: results of a prospective randomised trial. Scand J Plast Reconstr Surg Hand Surg. 2006; 40(1): 19-23. PMID 16428209
16. Freire M, Neto MS, Garcia EB, et al. Functional capacity and postural pain outcomes after reduction mammaplasty. Plast Reconstr Surg. Apr 01 2007; 119(4): 1149-1156. PMID 17496584
17. Saariniemi KM, Joukamaa M, Raitasalo R, et al. Breast reduction alleviates depression and anxiety and restores self-esteem: a prospective randomised clinical trial. Scand J Plast Reconstr Surg Hand Surg. 2009; 43(6): 320-4. PMID 19995250
18. Singh KA, Losken A. Additional benefits of reduction mammaplasty: a systematic review of the literature. Plast Reconstr Surg. Mar 2012; 129(3): 562-570. PMID 22090252
19. Torresetti M, Zuccatosta L, Di Benedetto G. The effects of breast reduction on pulmonary functions: A systematic review. J Plast Reconstr Aesthet Surg. Dec 2022; 75(12): 4335-4346. PMID 36229312
20. Hernanz F, Fidalgo M, Muñoz P, et al. Impact of reduction mammoplasty 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): e168-73. PMID 27344408
21. Kerrigan CL, Collins ED, Kim HM, et al. Reduction mammaplasty: defining medical necessity. Med Decis Making. 2002; 22(3): 208-17. PMID 12058778
22. 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): 1688-93. PMID 19692299
23. 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. PMID 21666541

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23. 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. PMID 22094737
24. 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 01 2013; 33(8): 1140-7. PMID 24214951
25. 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): 334-9. PMID 24506446
26. American Society of Plastic Surgeons. Reduction Mammaplasty: ASPS Recommended Insurance Coverage Criteria for Third-Party Payers. 2021; https://www.plasticsurgery.org/documents/Health- Policy/Reimbursement/insurance-2021-reduction-mammaplasty.pdf. Accessed December 13, 2022.

27. 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. PMID 35006204

    Endnotes

    1 Based on expert opinion