Humana Reduction Mammaplasty - Medicare Advantage Form

Please refer to CMS website for the most current applicable National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/CMS Online Manual System/ Transmittals. Type Title ID Number Jurisdiction Medicare Administrative Contractors (MACs) Applicable States/Territories Reduction Mammaplasty Page: 2 of 9 Internet- Only Manuals (IOMs) Chapter 16 General Exclusions from Coverage; Section 120 Cosmetic Surgery Medicare Benefit Policy Manual LCD LCA Cosmetic and Reconstructive Surgery L39051 A58774 LCD Reduction Mammaplasty L35001 LCD LCA Cosmetic and Reconstructive Surgery L39506 A59299 LCD LCA LCD LCA LCD LCA LCD LCA LCD LCA Plastic Surgery Plastic Surgery Cosmetic and Reconstructive Surgery Cosmetic and Reconstructive Surgery Cosmetic and Reconstructive Surgery L35163 A57221 L37020 A57222 L35090 A56587 L33428 A56658 L38914 A58573 J5, J8 - Wisconsin Physicians Service Insurance Corporation J6, JK - National Government Services, Inc. (Part A/B MAC) J15 - CGS Administrators, LLC (Part A/B MAC) JE - Noridian Healthcare Solutions, LLC JF - Noridian Healthcare Solutions, LLC JH, JL - Novitas Solutions, Inc. (Part A/B MAC) JJ, JM - Palmetto GBA (Part A/B MAC) JN - First Coast Service Options, Inc. (Part A/B MAC) IA, KS, MO, NE IN, MI IL, MN, WI CT, NY, ME, MA, NH, RI, VT KY, OH CA, HI, NV, American Samoa, Guam, Northern Mariana Islands AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY AR, CO, NM, OK, TX, LA, MS DE, D.C., MD, NJ, PA AL, GA, TN NC, SC, VA, WV FL, PR, U.S. VI Description Macromastia, also referred to as breast hypertrophy 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. Reduction Mammaplasty Page: 3 of 9 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. Coverage Determination Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare. In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the following criteria: Some MACs incorporate the use of the Schnur sliding scale as an evaluation tool for physicians to use with individuals considering breast reduction surgery. If an individual’s body surface area and weight of breast tissue proposed for removal fall above the 22nd percentile, then the surgery is generally considered medically reasonable and necessary with the appropriate criteria. This resource can be found in Appendix A. Reduction mammaplasty will be considered medically reasonable and necessary when the following requirements are met: • Diagnosis of macromastia; AND • Female 18 years of age or older or for whom breast growth is complete; AND • Documentation supporting the proposed amount of tissue to be removed is indicated; AND • One or more of the following conditions: o 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 dermatological therapy (eg, topical antibiotic, antifungal, corticosteroid cream) or other prescribed treatment if medically appropriate and not contraindicated; o Functional impairment* adversely affecting activities of daily living due to severe headache, 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; o Significant thoracic kyphosis directly correlated to the breast hypertrophy; o Chronic breast pain due to excessive breast weight AND presence of at least one other condition from this list, Reduction Mammaplasty Page: 4 of 9 o Shoulder grooving from support garment (eg, bra strap) with presence of skin irritation; o Shoulder grooving without skin irritation AND presence of at least one other condition from this list) **Conservative treatment includes 3 months of nonsurgical 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. Reduction mammaplasty of the unaffected/contralateral breast will be considered medically reasonable and necessary when performed to produce a symmetrical appearance following a medically necessary mastectomy or lumpectomy due to breast cancer. The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy. Coverage Limitations US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage Cosmetic surgery or expenses incurred in connection with such surgery is not a covered Medicare benefit. Cosmetic surgery includes any surgical procedure directed at improving appearance, except when required for the prompt (ie, as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member. These treatments and services fall within the Medicare program’s statutory exclusion that prohibits payment for items and services that have not been demonstrated to be reasonable and necessary for the diagnosis and treatment of illness or injury (§1862(a)(1) of the Act). Reduction Mammaplasty Page: 5 of 9 Note: This exclusion does not apply to surgery for therapeutic purposes which coincidentally also serves some cosmetic purpose.17