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Medical Policy: 07.01.20
Original Effective Date: January 1996
Reviewed: October 2007
Revised: October 2007
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
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.
Policy:
Prior approval is recommended. Submit a prior approval now.
Reduction mammoplasty may be considered medically necessary for macromastia when at least one of the following clinical indications and physical findings are present:
- There is a least a 6 week history of shoulder, neck or back pain related to macromastia that is not responsive to conservative therapy, such as an appropriate sports bra, exercises, heat or cold treatments, and appropriate non-steroidal anti-inflammatory agents or muscle relaxants.
- Ulceration of the skin on the shoulder or shoulder grooving.
- Intertrigo between the pendulous breast and the chest wall.
In addition to the above clinical indications, the following criteria must also be met:
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The patient must be old enough that the breasts are fully developed
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Average weight of tissue planned to be removed in each breast is above the 22nd percentile on the Schnur Sliding Scale (see below) based on the patient's body surface area (BSA)
Schnur Sliding Scale
Body Surface Area and Cutoff Weight of Breast Tissue Removed
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Breast Reduction (gm)
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Body Surface Area (m2)
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Lower 5%
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Lower 22%
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1.35
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127
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199
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1.40
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139
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218
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1.45
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152
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238
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1.50
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166
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260
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1.55
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181
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284
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1.60
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198
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310
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1.65
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216
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338
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1.70
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236
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370
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1.75
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258
|
404
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1.80
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282
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441
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1.85
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308
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482
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1.90
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336
|
527
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1.95
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367
|
575
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2.00
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401
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628
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2.05
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439
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687
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2.10
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479
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750
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2.15
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523
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819
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2.20
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572
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895
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2.25
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625
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978
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2.30
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682
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1068
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2.35
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745
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1167
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2.40
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814
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1275
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2.45
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890
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1393
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2.50
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972
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1522
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2.55
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1062
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1662
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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, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- CPT code 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.
- Medical College of Georgia; Department of Pediatrics. Continuity Clinic Notebook: Chapter 3; Tanner Staging. Also available at http://www.mcg.edu/pediatrics/ccnotebook/chapter3/tanner.htm
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309
*Prior approval is recommended for this policy.
**Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
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
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constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
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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.
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