Sunflower Health Plan Reduction Mammoplasty and Gynecomastia Surgery (PDF) Form

Reduction mammoplasty, also known as breast reduction surgery, is a surgical procedure to reduce the weight, mass, and size of the breast in those with a female reproductive system. Gynecomastia surgery is the surgical correction of over-developed or enlarged breasts in those with a male reproductive system. Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. Policy/Criteria I. It is the policy of health plans affiliated with Centene Corporation® that reduction mammoplasty is medically necessary when the criteria in A or B below are met: A. Macromastia, all of the following: 1. Member/enrollee is ≥ 16 years of age or/or Tanner stage V of Tanner staging of sexual maturity (See Appendix A for Tanner Staging); 2. For adolescents, no breast growth equivalent to a change in cup size for at least 6 months; 3. The estimated amount of breast tissue to be removed meets the minimum weight requirement based on the members/enrollee’s body surface area (BSA) per Appendix B, adapted from the Schnur Sliding Scale. The DuBois and DuBois body surface calculator (found here: http://www-users.med.cornell.edu/~spon/picu/calc/bsacalc.htm) may be used to calculate BSA if only height and weight are given; 4. Member/enrollee has at least two of the following persistent symptoms, affecting activities of daily living for at least one year: a. Headaches associated with neck and upper back pain; b. Pain in neck, shoulders, or upper back not related to other causes (e.g., poor posture, acute strains, poor lifting techniques); c. Breast pain; d. Painful kyphosis documented by X-rays; e. Pain/discomfort/ulceration/grooving from bra straps cutting into shoulders; f. Paresthesia of upper extremities due to brachial plexus compression syndrome g. Intertrigo; h. Significant discomfort resulting in severe restriction of physical activities; 5. Physician evaluation has determined all of the following: a. Pain is unresponsive to conservative treatment as evidenced by physician documentation of therapeutic measures including at least two of the following: i. Analgesic/non-steroidal anti-inflammatory drugs (NSAIDs); ii. Physical therapy/exercise when skeletal pathology is present; iii. Supportive devices (e.g., proper bra support, wide bra straps); iv. Medically supervised weight loss program; v. Chiropractic care or osteopathic manipulative treatment; Page 1 of 9 CLINICAL POLICY Reduction Mammoplasty and Gynecomastia Surgery vi. Orthopedic or spine surgeon evaluation of spinal pain; b. The pain is not associated with another diagnosis, e.g. arthritis; c. There is a reasonable likelihood that the members/enrollee’s symptoms are primarily due to macromastia; d. Reduction mammoplasty is likely to result in improvement of the chronic pain; e. Members/enrollees ≥ 40 years of age are required to have a mammogram that was negative for cancer performed within the year prior to the date of the planned reduction mammoplasty procedure. B. Gigantomastia of Pregnancy The member/enrollee has gigantomastia of pregnancy, accompanied by any of the following complications, and delivery is not imminent: 1. Massive infection; 2. Significant hemorrhage; 3. Tissue necrosis with slough; 4. Ulceration of breast tissue; 5. Intertriginous maceration or infection of the inframammary skin refractory to dermatologic measures. II. It is the policy of health plans affiliated with Centene Corporation that ] gynecomastia surgery is considered medically necessary when the criteria in A or B are met: A. Adolescents < 18 years Adolescents with unilateral or bilateral grade II, III, or IV gynecomastia (per Appendix C), and meets all of the following: 1. Persists for at least two years after pathological causes are ruled out; 2. Persists without improvement after appropriate treatment for at least six months for any underlying cause, including discontinuation of gynecomastia-inducing drugs and/or substances; 3. Experiences pain and discomfort due to the distention and tightness from the hypertrophied breast(s) that has not responded to medical management. 4. Adult testicular size is attained. B. Adults ≥ 18 years, meets all of the following: 1. Unilateral or bilateral grade III or IV gynecomastia (per Appendix C); 2. Glandular breast tissue is the primary cause of the gynecomastia; 3. Persists for at least one year after pathological causes are ruled out; 4. Persists without improvement after appropriate treatment for at least six months for any underlying cause, including appropriate discontinuation of gynecomastia-inducing drugs and/or substances; 5. Experiences pain and discomfort due to the distention and tightness from the hypertrophied breast(s) that has not responded to medical management; 6. Malignancy has been ruled out. Medical Record Documentation Requirements Medical records must accompany all requests for reduction mammoplasty and gynecomastia procedures, along with detailed documentation supporting the medical necessity of breast reduction, Page 2 of 9 CLINICAL POLICY Reduction Mammoplasty and Gynecomastia Surgery which should include height and weight information. When applicable, there must be documented evidence of conservative therapies attempted in order to substantiate that the condition is refractory to treatment. Photographic documentation may be requested to support written documentation.3,4 Background Reduction mammoplasty is the surgical reduction of breast size. It was originally adopted in medical practice in the 1920s.15 The surgery was proposed as a means of alleviating physical problems associated with excessive breast size and breast ptosis. Among these problems are pain in the neck, upper and lower back, shoulder, arm, and breast; headaches; paresthesia of the upper extremities; intertrigo (inflammation of skin folds); itching; striae; difficulty exercising; postural changes; inability to find appropriate clothing; bra strap grooving; difficulty sleeping; and psychological illnesses including anxiety and depression. Radiographic evidence of chronic postural changes has also been demonstrated. Reduction mammoplasty is also performed for many patients who request surgery to address breast deformities or asymmetry.1,9 Several procedures are available to accomplish breast reduction. Each procedure has its own unique approach to breast reshaping through various methods of skin incisions and resection patterns. Currently, the two surgical approaches to reduction mammoplasty most widely used are the Wise pattern reduction mammoplasty and vertical pattern breast reduction. The Wise pattern reduction mammoplasty is most commonly used in the United States, and the vertical pattern breast reduction is more popular in Europe. Both are pedicle-based procedures, with the Wise pattern scars entirely below the nipple and the vertical pedicle scars above the nipple. A crescent-shaped mass of tissue is removed from the inferior portion of each breast, and the skin is resected and sutured. Both grafting and pedicle- based techniques are used in cases where it is necessary to reposition the nipple-areola complex. These procedures seek to preserve the blood and nerve supply to the nipple- areola complex and create a symmetrical and natural appearance, while reducing breast volume and weight. Care is also taken to avoid scars that may be visible when the patient is clothed.1,9 Gestational gigantomastia is a rare clinical condition, characterized by rapid and disproportionate enlargement of the breasts during pregnancy. Patients present with massive enlargement of the breasts accompanied by possible thinning of the skin, tissue necrosis, infection, and hemorrhage. Treatment methods include medical therapy and surgery. When conservative treatment is ineffective or patients present with complications, (e.g., massive hemorrhage, ulceration, or breast necrosis), a surgical approach is indicated. Currently available surgical interventions are either breast reduction or mastectomy with delayed reconstruction.17 Gynecomastia is the benign proliferation of glandular breast tissue in those with a male reproductive system. Physiologic gynecomastia is common in newborns, adolescents, and those older than 50 years of age. In newborns and adolescents, it generally resolves spontaneously without intervention. In this older age group, decreasing free-testosterone levels can contribute to physiologic gynecomastia. However, they are less likely to present for evaluation and treatment than adolescents.8,16 Non-physiologic gynecomastia can occur at any age and can be a result of a medical condition, medication use, or substance abuse. Persistent pubertal gynecomastia is the most common cause of non-physiologic gynecomastia. It generally resolves six months to two years after onset. However, if Page 3 of 9 CLINICAL POLICY Reduction Mammoplasty and Gynecomastia Surgery symptoms persist after two years, or after 17 years of age, further evaluation is needed to determine cause and appropriate treatment. Medications such as antipsychotics, antiretrovirals, and prostate cancer therapies are common triggers, as well as non-prescription drugs such as performance- enhancing supplements and anabolic steroids. Common medical conditions that can cause gynecomastia include Klinefelter’s syndrome, adrenal tumors, brain tumors, chronic liver disease, androgen deficiency, endocrine disorders, and testicular tumors.5,8,16 Tanner Stage 1 (Prepubertal) 2 Appendices Appendix A Criteria for distinguishing Tanner stages 1 to 5 in those with a female reproductive system Pubic Hair No pubic hair; short, fine villus hair only Sparse, long pigmented terminal hair chiefly along the labia majora Dark, coarse, curly hair, extending sparsely over mons Breast No palpable glandular tissue or pigmentation of areola; elevation of areola only Glandular tissue palpable with elevation of breast and areola together as a small mound; areola diameter increased 3 4 5 (Adult) Further enlargement without separation of breast and areola; although more darkly pigmented, areola still pale and immature; nipple generally at or above mid-plane of breast tissue when individual is seated upright Secondary mound of areola and papilla above breast Recession of areola to contour of breast; development of Montgomery’s glands and ducts on the areola; further pigmentation of areola; nipple generally below mid-plane of breast tissue when individual is seated upright; maturation independent of breast size Adult-type hair, abundant but limited to mons and labia Adult-type hair in quantity and distribution; spread to inner aspects of the thighs in most racial groups Appendix B Adapted from Schnur Sliding Scale13 – body surface area and estimated minimum cutoff weight for breast tissue per breast to be removed. Body Surface Area (m2) 1.35 1.40 1.45 1.50 1.55 1.60 1.65 1.70 1.75 Weight of tissue to be removed per breast (grams) 199 218 238 260 284 310 338 370 404 Body Surface Area (m2) 1.80 1.85 1.90 1.95 2.00 2.05 2.15 2.20 2.25 Weight of tissue to be removed per breast (grams) 441 482 527 575 628 687 819 895 978 Page 4 of 9 CLINICAL POLICY Reduction Mammoplasty and Gynecomastia Surgery Body Surface Area (m2) ≥ 2.30 Weight of tissue to be removed per breast (grams) 1000 Appendix C Gynecomastia Scale adapted from the McKinney and Simon, Hoffman and Kohn scales:4 I. Grade I: Small breast enlargement with localized button of tissue that is concentrated around the areola II. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest III. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present IV. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. Coding Implications This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2019, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. CPT®* Codes 19300 19318 Mastectomy for gynecomastia Breast reduction ICD-10-CM Diagnosis Codes that Support Coverage Criteria - ICD 10 CM Code - Other headache syndrome G44.89 Brachial plexus disorders G54.0 Erythema intertrigo L30.4 Pain in shoulder M25.511 through M25.519 M40.00 through M40.05 M40.10 through M40.15 M40.202 through M40.205 M40.292 through M24.295 Other secondary kyphosis Unspecified kyphosis Postural kyphosis Other kyphosis Page 5 of 9 CLINICAL POLICY Reduction Mammoplasty and Gynecomastia Surgery CEN"l'.'ENE" ~·orporatwn - - ICD 10 CM Code M54.2 M54.9 N62 N64.4 Q98.4 Cervicalgia Dorsalgia, unspecified Hypertrophy of breast Mastodynia Klinefelter’s syndrome, unspecified Reviews, Revisions, and Approvals Policy developed. Specialist reviewed Table formatting updated I.A.3.a added that headaches are associated with neck and upper back pain; I.A.3.b added that pain is not related to other causes; I.A.4.a added medically supervised weight loss and orthopedic evaluation as options. Added ICD-10 codes. Reworded I.A.2. for clarity. Added “Significant discomfort resulting in severe restriction of physical activities” to I.A.3 based on UpToDate patient selection criteria. Added “chiropractic care or osteopathic manipulative treatment” under I.A.4. References reviewed and updated. Specialist reviewed. Added note to reference CP.MP.95 for breast surgeries pertaining to gender affirming procedures. Added criteria for breast reduction for females that cup size has not changed in 6 months. Added criteria for adolescent males requiring that adult testicular size has been attained. References reviewed and updated. Revised description of CPT-19318. Replaced all instances of “member” with “member/enrollee” Annual review. Deleted “for non-cosmetic reasons” from the policy statement in I, as it is redundant given the symptom criteria required. Replaced "and/or" with "or" in I.A.1. Reworded paragraph under Medical Record Documentation Requirements for both reduction mammoplasty and gynecomastia, and changed requirement of photographic documentation to “photographic documentation may be requested to support written documentation.” References reviewed and updated. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date." Specialist reviewed. In I.A.2., changed “No change in cup size for at least 6 months” to “For adolescents, no breast growth equivalent to a change in cup size for at least 6 months.” Updated background regarding gigantomastia of pregnancy with no impact on criteria. Annual review completed. Changed “women” to “members/enrollees” in I.A.5.c. Added I.B.5. to gigantomastia of pregnancy criteria. Language references in the criteria, description and background Revision Date 06/12 08/16 Approval Date 08/12 09/16 09/17 09/17 07/18 07/19 07/20 07/18 06/19 06/20 04/21 07/21 07/21 09/21 09/21 07/22 07/22 Page 6 of 9 CLINICAL POLICY Reduction Mammoplasty and Gynecomastia Surgery Reviews, Revisions, and Approvals sections changed from “male” and/or “female” to “those with a male reproductive system” and/or “those with a female reproductive system.” References reviewed and updated. CEN"l'.'ENE" ~·orporatwn Revision Date Approval Date