Reduction Mammoplasty*

Medical Policy: 07.01.20 
Original Effective Date: January 1996 
Reviewed: March 2012 
Revised: June 2011 

Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

Description: 

Reduction mammoplasty is a surgical procedure to reduce the size of the breast. It is usually performed bilaterally and limited to medically necessary and non cosmetic procedures. The record should reflect the patient’s height and weight and the anticipated amount of breast tissue to be removed, and that the size and shape of the breast is causing the symptoms.

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Prior Approval: 

Prior approval is recommended. Submit a prior approval now. 

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Policy: 

Reduction mammoplasty may be considered medically necessary when all of the following criteria are met:

• Patient is at least 18 years of age.
• Women 40 years of age or older are required to have a mammogram that was negative for cancer within the year prior to the date of the planned procedure.

AND

• Expected tissue removal of at least:
  • 300 grams* per breast for women with height less then 5’2” or weight less than 120 lbs
  • 400 grams* per breast for women with height greater than or equal to 5’2” and weight between 120 lbs and 180 lbs.
  • 600 grams* per breast for women with height greater than or equal to 5’2” and weight greater than 180 lbs.

*Planned amount of tissue to be removed may be within 50 grams of what is expected.

NOTE: If significant asymmetry exists, the grams of tissue to be removed from at least one breast must comply with the criteria outlined above.

AND

• There is a documented history of one of the following functional impairments for six months or greater:
  • 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 non-steroidal anti-inflammatory agents/muscle relaxants
  • Intertrigo between the pendulous breast and the chest wall

Reduction mammoplasty is considered not medically necessary for any circumstances not listed above.

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
• 19318 reduction mammoplasty.

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Selected References: 

• Brown DM, Young VL. Reduction mammoplasty for macromastia. Aesthetic Plastic Surgery 1993 Summer; 17(3): 211-23.
• Howrigan PJ. Reduction and augmentation mammoplasty. Obstetrics and Gynecology Clinics of North America 1994 Sep;2 (3): 539-49.
• Mizgala CL, MacKenzie KM. Breast reduction outcome study. Annuals of Plastic Surgery 2000 Dec: 45(2):125-33.
• Behmand RA, Tang DH, Smith DJ JR. Outcomes in breast reduction surgery. Annals of Plastic Surgery2000; 45(6): 575-580.
• Chadbourne EB, Zhang S, et al. Clinical outcomes in reduction mammaplasty: a systematic review and meta-analysis of published studies. Mayo Clin Proc. 2001 May;76(5):503-10.
• Tanner JM, Davies PS. Clinical longitudinal standards for height and height velocity for North American children. J Pediatr. 1985 Sep;107(3):317-29.
• ECRI. Female breast reduction surgery. Plymouth Meeting, PA: ECRI Health Technology Information Service; 2005 June 14. 8 p. (ECRI Hotline Response). Also available: http://www.ecri.org.
• American Society of Plastic Surgeons. Position paper: Reduction Mammaplasty; ASPS Recommended Insurance Coverage Criteria for Third-Party Payers. March 2002. Available at: http://www.plasticsurgery.org/medical_professionals/health_policy/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=4534. Accessed September 9, 2008.  

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Policy History: 

Date                                        Reason                               Action

March 2011                            Annual review                    Policy renewed

June 2011                              Interim review                     Policy revised

March 2012                           Annual review                     Policy renewed

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Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.