Reduction Mammoplasty*

Medical Policy: 07.01.20 
Original Effective Date: January 1996 
Reviewed: September 2008 
Revised: September 2008 

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 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.

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 macromastia with at least two of the following functional impairments for six months or greater:
    • Persistent shoulder grooving despite the use of support devices (appropriate support bra, wide strap bra)
    • Chronic submammary intertriginous rash causing cellulitis, skin necrosis, and/or ulceration unresponsive to dermatologic treatment (i.e., antibiotics or antifungal therapy)
    • Chronic neck, back, and shoulder pain and/or occipital headaches.

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.
  • 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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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.

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