Humana Reduction Mammaplasty Form

Description

Macromastia is excessive development of the mammary glands (breasts) disproportionate to the body. Reduction mammaplasty (also spelled mammoplasty), or breast reduction surgery, reduces the volume and weight of the breasts by removing excess glandular tissue, skin and subcutaneous fat. The goals of the surgery are to relieve symptoms caused by heavy breasts, to create a natural, balanced appearance with normal location of the nipple and areola, to maintain the capacity for lactation and allow for future breast exams/mammograms, with minimal scarring or decreased sensation.

The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. Excess breast tissue, fat and skin are removed, and placement of the nipple and areola are adjusted.

Page: 1 of 7

Reduction Mammaplasty

Effective Date: 07/27/2023

Revision Date: 07/27/2023

Review Date: 07/27/2023

Policy Number: HUM-0403-026 Page: 2 of 7

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

In a liposuction-only reduction mammaplasty, a small access incision is made in one of the following locations: axillary (under the arm), periareolar (around the nipple) or in the inframammary fold (under the breast). Anesthesia may be injected along with saline solution until the tissue is firm, and a suction cannula is used to extract fat from the breast. (Refer to Coverage Limitations Section)

For information about reduction mammaplasty or breast surgery related to conditions not addressed in this policy, please see the following:

• Procedure: Surgical treatment of enlarged male breast - Medical Coverage Policy: Gynecomastia Surgery
• Procedure: Breast reduction prior to a nipple-sparing mastectomy for breast cancer - Medical Coverage Policy: Breast Reconstruction
• Procedure: Breast reduction in the context of gender affirming chest surgery - Medical Coverage Policy: Gender Affirmation Surgery

Coverage Determination

Any state mandates for reduction mammaplasty take precedence over this medical coverage policy.

Commercial Plan members: requests for reduction mammaplasty for an individual with body surface area (BSA) greater than or equal to 2.60 require review by a medical director.

Humana members may be eligible under the Plan for reduction mammaplasty when the following criteria are met:

• Based on the individual’s BSA, using the DuBois formula, tissue to be removed from each breast is expected to be greater than or equal to the 22nd percentile of the Schnur sliding scale (see BSA calculation and Schnur sliding scale); AND
• Diagnosis of macromastia; AND
• Female 18 years of age or older or for whom breast growth is complete; AND

Reduction Mammaplasty Effective Date: 07/27/2023

Revision Date: 07/27/2023

Review Date: 07/27/2023

Policy Number: HUM-0403-026 Page: 3 of 7

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Mammogram performed within 12 calendar months prior to the date of the scheduled procedure negative for suspected cancer (applicable to individuals 40 years of age or older without a known breast cancer diagnosis); AND
• One of the following conditions:
  • Medical complications due to refractory skin breakdown (eg, severe soft tissue infection, tissue necrosis, ulceration, hemorrhage) resulting from overlying breast tissue, not relieved or controlled by at least 3 months of dermatological therapy (eg, topical antibiotic, antifungal, corticosteroid cream) or other prescribed treatment if medically appropriate and not contraindicated; OR
  • Functional impairment* adversely affecting activities of daily living due to severe back, neck and/or shoulder pain or upper extremity paresthesia directly attributable to macromastia, refractory to conservative treatment** and no other etiology has been found on medical evaluation

*Conservative treatment includes 3 consecutive months of medical management, including at least one of the following:

• Chiropractic care or osteopathic manipulative treatment; OR
• Medically prescribed exercise regimen; OR
• Medically supervised weight loss program; OR
• NSAIDS and/or skeletal muscle relaxants if medically appropriate and not contraindicated; OR
• Physical therapy

*Functional impairment is defined as a direct and measurable reduction in physical performance of an organ or body part.

Humana members may be eligible under the Plan for reduction mammaplasty of the unaffected/contralateral breast when performed to produce a symmetrical appearance following a medically necessary mastectomy or lumpectomy due to breast cancer.

Coverage Limitations

Humana members may NOT be eligible under the Plan for reduction mammaplasty for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member's individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for liposuction-only reduction mammaplasty. This is considered experimental/investigational as it is not identified as safe, widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Additional information about macromastia may be found from the following websites:

• Background
  • American Society of Plastic Surgeons
  • National Library of Medicine
• Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.