Medical Policy


Subject:Reduction Mammaplasty
Policy #:  SURG.00086Current Effective Date:  04/15/2014
Status:ReviewedLast Review Date:  02/13/2014

Description/Scope

Reduction mammaplasty refers to plastic surgery of the breast to reduce its volume by excision of tissue and (frequently) to improve its shape and position. This document addresses reduction mammaplasty only and is not intended for application to those undergoing reconstructive procedures after surgery for breast cancer or other clinical indications.  

Note: For information related to mastectomy for gynecomastia and other breast procedures including reconstructive surgery and implants, refer to:

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant physical functional impairment, AND the procedure can be reasonably expected to improve the physical functional impairment.

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those that are primarily intended to preserve or improve appearance.

Position Statement

Medically Necessary:

Reduction mammaplasty is considered medically necessary when either of the following criteria (I or II) are met: 

  1. Individuals meeting BOTH of the following criteria (A and B):
    1. Presence of one or more of the following that has persisted for at least one year:
      1. A cervical or thoracic pain syndrome (upper back and shoulder pain), in which interference with daily activities or work has been documented. The pain is not associated with other diagnoses (i.e., arthritis, multiple sclerosis, cervical spine disease, etc. have been adequately ruled-out by means of diagnostics, as applicable), and there has been at least three (3) months of adequate conservative treatment with one or more of the following: special support garments (e.g., special support bras, bras with wide straps), NSAIDs, physical therapy, or similar modalities; or
      2. Submammary intertrigo that is refractory to conventional medications and measures used to treat intertrigo, or shoulder grooving with ulceration unresponsive to conventional therapy; or
      3. Thoracic outlet syndrome (to include ulnar paresthesias from breast size) that has not responded to at least three (3) months of adequate conservative treatment.
    2. The preoperative evaluation by the surgeon concludes that an appropriate amount of breast tissue, per breast, will be removed, based upon body surface area or total mass to be removed and that there is a reasonable prognosis of symptomatic relief. The request for surgery must include: the individual's height and weight; the size and shape of the breast(s) causing symptoms; the anticipated amount of breast tissue to be removed. Pictures may be requested to document medical necessity.

      Note: Medical records from the primary care physician and other providers (e.g. physiatrist, orthopedic surgeon, etc.) who have diagnosed or treated the symptoms prompting this request may also be required.  

      The appropriate amounts (in grams) of breast tissue must be anticipated for removal from at least one breast, which is based on the individual's total body surface area (BSA) in meters squared. See Appendix for a table relating BSA values to the minimum amount (weight) of breast tissue to be removed per breast.   

      To calculate body surface area see: http://www.medcalc.com/body.html.

      OR
  2. Individuals, regardless of BSA, who are anticipated to have at least 1 kg. of breast tissue removed from each breast and who meet the following criteria:
    Presence of one or more of the following that has persisted for at least one year:
      1. A cervical or thoracic pain syndrome (upper back and shoulder pain), in which interference with daily activities or work has been documented. The pain is not associated with other diagnoses (i.e., arthritis, multiple sclerosis, cervical spine disease, etc. have been adequately ruled-out by means of diagnostics, as applicable), and there has been at least three (3) months of adequate conservative treatment with one or more of the following: special support garments (e.g., special support bras, bras with wide straps), NSAIDs, physical therapy, or similar modalities; or
      2. Submammary intertrigo that is refractory to conventional medications and measures used to treat intertrigo, or shoulder grooving with ulceration unresponsive to conventional therapy; or
      3. Thoracic outlet syndrome (to include ulnar paresthesias from breast size) that has not responded to at least three (3) months of adequate conservative treatment.

Not Medically Necessary:

Breast reduction surgery is considered not medically necessary when the criteria above are not met.

Investigational and Not Medically Necessary:

The use of liposuction to perform breast reduction is considered investigational and not medically necessary.

Cosmetic and Not Medically Necessary:

Breast reduction surgery is considered cosmetic and not medically necessary for the following conditions: poor posture, breast asymmetry, pendulousness, problems with clothes fitting properly and nipple-areola distortion or psychological considerations.

Rationale

In many instances, extremely large breasts (e.g. macromastia or breast hypertrophy) have been associated with the development of back, neck and shoulder pain; redness, burning, itching, skin disintegration and cracking; secondary infections, loss of feeling and weakness. Obviously, such symptoms have significant negative impact on the quality of life and may limit physical functioning. In the absence of such symptoms, breast reduction has also been used as a technique to enhance the appearance of the breast for cosmetic purposes.

When the above symptoms exist and cannot be alleviated by conservative methods, such as pain medication, physical therapy, and skin ointments or powders, surgical intervention to reduce the size of the breasts may be indicated. In such cases, scientific studies have shown that a significant amount of breast tissue must be removed, in order to alleviate physical symptoms. Debate has occurred surrounding what should be considered an adequate amount of breast tissue to be removed to achieve adequate symptomatic relief. The medical literature supports an approach, based upon the measurement of body surface area (i.e., the Schnur scale). The use of the Schnur scale for this measurement is in keeping with accepted medical opinion and the medical evidence, since it is important that an adequate amount of breast tissue be removed, in order to maximize the probability of symptomatic relief. Additionally, specialty consensus opinion agrees that breasts are considered paired organs and it is not possible to definitively relate symptoms to one breast or the other. Therefore, bilateral breast reduction mammaplasty may be considered appropriate if the amount of breast tissue anticipated for removal from at least one breast meets the minimum amount (weight) per the Schnur scale and all other criteria are met.

Schnur and colleagues (1991) reported the results of two surveys sent to 220 randomly selected board certified plastic surgeons who performed reduction mammaplasties. Ninety-two plastic surgeons returned survey data on 600 women on whom reduction mammaplasty had been performed. Data obtained from the first survey included the height and weight of the individual, as well as the amount of breast tissue removed from each breast. The second survey resulted in an estimate of percentages of women who sought a reduction mammaplasty for purely cosmetic reasons, for purely medical reasons, and for mixed reasons. Based on the results obtained, the authors concluded that if the removed breast tissue weight was greater than the 22nd percentile, her motivation for the surgery was medical and if the removed breast tissue weight was less than the 5th percentile, the procedure was sought for cosmetic reasons. Those women whose removed breast tissue weight was between the 5th and the 22nd percentile reportedly had mixed reasons for requesting the procedure. In a subsequent outcome study, based on questionnaire responses from women who had undergone reduction mammaplasty, Schnur (1997), reported that in properly selected individuals, reduction mammaplasty is a safe and effective procedure for relieving or improving symptoms related to symptomatic macromastia.

Chadbourne and colleagues (2001) conducted a systematic review and meta-analysis on 29 studies and 4173 individuals. A review of the literature was performed from 1985 until March 1999. Eligible studies were experimental and observational. The studies involved females with preoperative physical or psychosocial signs and symptoms who underwent reduction mammaplasty for breast hypertrophy. Outcomes assessed included postoperative signs and symptoms, such as shoulder pain, shoulder (bra strap) grooving, and quality of life domains. Statistically significant improvement of signs and symptoms was seen between preoperative and postoperative periods. Limitations of the review include recall bias, a high proportion of individuals (25%) without follow-up results, and arbitrary outcome formats (Chadbourne, 2001). Key limitations of this publication are the inherent limitations of "meta-analysis" for evaluating studies which are not randomized controlled trials and that this study was not designed to determine a threshold for weight of tissue to be removed to produce symptom relief.

Collins and colleagues (2002) conducted a prospective controlled study designed to evaluate the efficacy of breast reduction in alleviating symptoms of macromastia by comparing baseline and postoperative health status. Standard outcome instruments were utilized in the study and consisted of the SF-36, EuroQol, Multidimensional Body-Self Relations Questionnaire (MBSRQ), and the McGill Pain Questionnaire (MPQ). The study involved 179 subjects with matched preoperative and postoperative data sets, 96 controls and 88 hypertrophy controls. The women were mainly Caucasian, middle-aged, well educated, and employed. Data from completed questionnaires were gathered preoperatively and then approximately 6 to 9 months post surgery. Outcomes demonstrated that subjects preoperatively had lower scores (p<0.05) in all health domains of the SF-36 and in the mental and physical component summary scores. After surgery, the same group of subjects measured higher than national norms in 7 of the 8 health domains. Preoperative pain scores measured with a Pain Rating Index (PRI) score from the MPQ were reported to be 26.6 and after surgery, pain was stated to be lower with a score of 11.7. Study limitations include non randomization and the possibility that women in this study may have overstated their symptoms or lack of effectiveness of nonsurgical treatments (Collins, 2002). Also, the study was not designed to determine a threshold for weight of tissue to be removed to produce symptom relief and there was no comparison of resection weight and extent of symptom relief.

Cunningham and colleagues (2005) analyzed complication data from the Breast Reduction Assessment: Value and Outcomes (BRAVO) Study by Collins (2002). Study data from 179 subjects post breast reduction surgery were analyzed and results demonstrated an overall complication rate of 43 percent (77 individuals). The most common complication was delayed wound healing. Other complications included splitting sutures, hematoma, nipple necrosis, hypertrophic scars, fat necrosis, seroma, and infection. The authors noted that average preoperative breast volume, a vertical incision, and preoperative shoulder grooving were associated with an increased incidence of complications while age, smoking status, body mass index, weight of breast tissue resected, pedicle type, keyhole incision, free nipple grafting, operative time, use of epinephrine, drains, and liposuction were not associated with an increased incidence of complications. The major weaknesses of the study include the small sample size, possible inconsistencies in defining and reporting complications, and the introduction of a new technique (vertical scar) during the study period (Cunningham, 2005).

Saariniemi and colleagues (2008) reported on a study assessing quality of life and pain in 82 women randomized to either reduction mammaplasty or a nonoperative group. Evaluations were performed at the onset of the study and six months later. The authors reported the mammaplasty group had significant improvements in quality of life, as measured by the physical summary score of the Short Form (SF)-36 quality-of-life questionnaire (change of +9.7 vs. +0.7, p<0.0001), the utility index score (SF-6D) (+17.5 vs. +0.6)., the index score of quality of life (SF-15D) (+8.6 vs. +0.06, p<0.0001), and the SF-36 mental summary score (+7.8 vs. -1.0, p<0.002). There were also improvements in breast-related symptoms, as measured by the Finnish Breast-Associated Symptoms questionnaire score (-47.9 vs. -3.5, p<0.0001), and the Finnish Pain Questionnaire score (-21.5 vs. -1.0, p<0.0001). This study was limited by a small sample size and lack of long-term follow-up.

The American Society of Plastic Surgeons (ASPS) (2011a; 2011b) issued a document on criteria for third-party payers and a companion practice guideline for reduction mammaplasty. Also, in 2012 Kallianen reviewed the ASPS guidelines and affirmed their 2011 recommendations. The ASPS indicates level I evidence has shown reduction mammaplasty is effective in treating symptomatic breast hypertrophy which is defined as a "syndrome of persistent neck and shoulder pain, painful shoulder grooving from brassiere straps, chronic intertriginous rash of the inframammary fold, and frequent episodes of headache, backache, and neuropathies caused by heavy breasts caused by an increase in the volume and weight of breast tissue beyond normal proportions." The ASPS also indicates volume or weight of breast tissue resection should not be criteria for reduction mammaplasty. If 2 or more symptoms are present all or most of the time, reduction mammaplasty is appropriate. Their position is largely based on observational studies which lack randomized control groups and have a potential for selection bias.

Gonzalez and colleagues (2012) reported on 178 women who had breast reduction surgery primarily for symptomatic macromastia. The Breast Q questionnaire was completed once after surgery, and retrospective chart reviews were also completed to assess individual outcomes and determine whether any correlation exists between outcomes and size or amount of breast tissue removed. Most of the women responded to the surgery with satisfaction with a mean response on the Breast Q questionnaire of 2.8 (2, somewhat agree; 3, definitely agree). The mean body mass index (BMI) reported was 28.3 kg/m and correlated significantly with the amount of breast tissue removed (p<0.0001). The mean combined total amount of breast tissue removed was 1,221 g but did not correlate significantly with quality-of-life responses (p=0.57).

Gust and colleagues (2013) performed a retrospective analysis of all reduction mammaplasties recorded in the National Surgical Quality Improvement Program database for 2006-2010. Complication rates across multiple institutions were stratified by BMI. In addition, data on demographics, comorbidities, medical and surgical complications, reoperation, and mortality were collected through 30 days post-surgery. Of 2492 women included in the study, 55% were considered obese (BMI >30). The overall surgical complication rate was 4.0%, increasing from 2.4% for BMI <25 to 7.1% for BMI >45 (P = .006), with an adjusted odds ratio of 2.97 for BMI >45 versus BMI <25. The most common surgical complication was superficial surgical site infection found in 2.9% of the women. Superficial surgical site infection increased from 2.1% for BMI <25 to 5.1% for BMI >45 (P = .03). The medical complication rate was 0.6%, and the reoperation rate was 2.1%. There were no deaths reported. Analysis showed that BMI ≥39 was associated with a significantly higher complication rate, with an odds ratio of 2.38. The authors concluded that reduction mammaplasty is a safe surgical procedure, even when performed on those with a high BMI. However, those with higher BMI have a greater risk of surgical site complications and the risk should be discussed preoperatively with obese individuals.

Finally, the use of liposuction, as the primary tool or as an adjunct for reduction mammaplasty, has not been adequately evaluated and has not been demonstrated to improve health outcomes in the medical literature. While there have been case series reported (Habbema, 2009; Sadove, 2005), a clinical trial comparing the use of liposuction to standard surgical reduction mammaplasty has not been conducted. In addition, the effectiveness of liposuction, in terms of removing glandular breast tissue, rather than fatty tissue in the breast, remains to be demonstrated. Thus, no clear conclusions can be drawn regarding the efficacy of liposuction, as a surgical technique for reduction mammaplasty.

In conclusion, there is a lack of prospective randomized clinical trials with appropriate controls assessing the efficacy of reduction mammaplasty on relief of symptoms. Evidence supporting the efficacy of this surgery includes multiple case series. Since the symptoms are thought to be the result of breast size, based upon the available peer reviewed literature, an individual's signs and symptoms and the amount of breast tissue to be removed should be evaluated before reduction mammaplasty is performed.

Background/Overview

Description of Technology

The most common method of breast reduction involves the surgical removal of skin, fat and breast tissue. The procedure is designed to reconstruct the breast with an aesthetically acceptable appearance, while reducing the breast mass. Another proposed method of mammaplasty involves the suction of fatty tissue from the breast (liposuction).

Proposed Benefits

Excess breast mass and weight is believed in some cases to lead to medical problems, such as various pain syndromes and submammary intertrigo (an inflammatory condition affecting the skin directly underneath the breast). Removal of excess breast tissue results in a decrease in breast mass and weight which should theoretically relieve the problems. In order to maximize the potential for symptomatic relief, it is important that an adequate amount of breast tissue be removed.

Possible Risks

Any major surgical treatment can result in significant risks, including the risks of general anesthesia, infection, and bleeding. However, there are no clear major risks unique to this procedure. In the event the individual develops symptoms of post-operative complications, such as elevated temperature, significant wound inflammation and increased drainage, inability to tolerate oral fluids or diet, increased pain, continued inpatient stay protocols would be implemented, consistent with medical review guidelines.

Definitions

Intertrigo: A skin condition that occurs in locations where two opposing skin surfaces meet, such as beneath pendulous breasts. Redness, burning, itching, infections, and occasionally skin disintegration and cracking characterize this condition.

Thoracic outlet syndrome: A condition resulting from constant pressure on the area between the neck and shoulder where many nerves and blood vessels are located. Symptoms may include pain, weakness, or numbness in the arm on the affected side, (i.e., ulnar paresthesias).

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

CPT 
19318Reduction mammaplasty
  
ICD-9 Procedure[For dates of service prior to 10/01/2014]
85.31Unilateral reduction mammoplasty
85.32Bilateral reduction mammoplasty
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
353.0Brachial plexus lesions (thoracic outlet syndrome)
611.1Hypertrophy of breast
611.81Ptosis of breast
  
ICD-10 Procedure[For dates of service on or after 10/01/2014]
0HBT0ZZExcision of right breast, open approach
0HBU0ZZExcision of left breast, open approach
0HBV0ZZExcision of bilateral breast, open approach
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2014]
G54.0Brachial plexus lesions (thoracic outlet syndrome)
N62Hypertrophy of breast
N64.81Ptosis of breast

When services are Not Medically Necessary:

For the procedure codes listed above when criteria are not met; or when the code describes a procedure indicated in the Position Statement section as not medically necessary.

When services are Cosmetic and Not Medically Necessary:

For the procedure codes listed above for the indications listed in the Position Statement section as cosmetic and not medically necessary; and for the following procedure codes:

ICD-10 Procedure[For dates of service on or after 10/01/2014]
0H0T0ZZAlteration of right breast, open approach
0H0U0ZZAlteration of left breast, open approach
0H0V0ZZAlteration of bilateral breast, open approach
0J060ZZAlteration of chest subcutaneous tissue and fascia, open approach

When services are Investigational and Not Medically Necessary:

CPT 
15877Suction assisted lipectomy; trunk [when used to report reduction mammaplasty performed by liposuction method]
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
611.1Hypertrophy of breast
611.81Ptosis of breast
612.1Disproportion of reconstructed breast
  
ICD-10 Procedure[For dates of service on or after 10/01/2014]
0J063ZZAlteration of chest subcutaneous tissue and fascia, percutaneous approach
0JD60ZZExtraction of chest subcutaneous tissue and fascia, open approach
0JD63ZZExtraction of chest subcutaneous tissue and fascia, percutaneous approach
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2014]
N62Hypertrophy of breast
N64.81Ptosis of breast
N65.1Disproportion of reconstructed breast
  
References

Peer Reviewed Publications:

  1. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has long-lasting effect. Ann Plastic Surg. 1998; 41(3):240-245.
  2. Chadbourne EB, Zhang S, Gordon MJ, et al. Clinical outcomes in reduction mammaplasty: a systemic review and meta-analysis of published studies. Mayo Clin Proc. 2001; 76(5):503-510.
  3. Chao JD, Memmel HC, Redding JF, et al. Reduction mammaplasty is a functional operation, improving quality of life in symptomatic women: a prospective, single-center breast reduction outcome study. Plast Reconstr Surg. 2002; 110(7):1644-1652.
  4. Collins ED, Kerrigan CL, Kim M, et al. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plast Reconstr Surg. 2002; 109(5):1556-1566.
  5. Cunningham BL, Gear AJ, Kerrigan CL, Collins ED. Analysis of breast reduction complications derived from the BRAVO study. Plast Reconstr Surg. 2005; 115(6):1597-1604.
  6. Dabbah A, Lehman JA Jr, Parker MG, et al. Reduction mammaplasty: an outcome analysis. Ann Plast Surg. 1995; 35(4):337-341.
  7. Davis GM, Ringler SL, Short K, et al. Reduction mammaplasty: long-term efficacy, morbidity, and patient satisfaction. Plast Reconstr Surg. 1995; 96(5):1106-1110.
  8. Di Giuseppe A. Breast reduction with ultrasound-assisted lipectomy. Plast Reconstr Surg. 2003; 112(1):71-82.
  9. Glatt BS, Sarwer DB, O'Hara DE, et al. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Plast Reconstr Surg. 1999; 103(1):76-82.
  10. Gonzalez F, Walton RL, Shafer B, et al. Reduction mammaplasty improves symptoms of macromastia. Plast Reconstr Surg. 1993; 91(7):1270-1276.
  11. Gonzalez MA, Glickman LT, Aladegbami B et al. Quality of life after breast reduction surgery: a 10-year retrospective analysis using the breast q questionnaire: does breast size matter? Ann Plast Surg 2012; 69(4):361-363.
  12. Gray LN. Update on experience with liposuction breast reduction. Plast Reconstr Surg. 2001; 108(4):1006-1010.
  13. Gust MJ, Smetona JT, Persing JS, et al. The impact of body mass index on reduction mammaplasty: a multicenter analysis of 2492 patients. Aesthet Surg J. 2013; 33(8):1140-1147.
  14. Habbema L. Breast reduction using liposuction with tumescent local anesthesia and powered cannulas. Dermatol Surg. 2009; 35(1):41-50; discussion 50-52.
  15. Hooper DM, Ricciardelli EJ, Goel VK, Aleksiev A. Biomechanical changes in the low back following reduction mammaplasty surgery. Clin Biomech (Bristol, Avon). 1997; 12(7-8):525-527.
  16. Kaminer MS, Tan MH, Hsu TS. Limited breast reduction by liposuction. Skin Therapy Lett. 2002; 7(10):6-8.
  17. Kerrigan CL, Collins ED, Kim HM, et al. Reduction mammaplasty: defining medical necessity. Med Decis Making. 2002; 22(3):208-217.
  18. Kerrigan CL, Collins ED, Kneeland TS, et al. Measuring health state preferences in women with breast hypertrophy. Plast Reconstr Surg. 2000. 106(2):280-288.
  19. Kompatscher P, von Planta A, Spicher I, et al. Comparison of the incidence and predicted risk of early surgical site infections after breast reduction. Aesthetic Plast Surg. 2003; 27(4):308-314.
  20. Matarasso A. Suction mammaplasty: the use of suction lipectomy to reduce large breasts. Plast Reconstr Surg. 2000; 105(7):2604-2607.
  21. Matarasso SL. Liposuction of chest and back. Dermatol Clin. 1999; 17(4):799-804.
  22. Miller AP, Zacher, Berggren RB, et al. Breast reduction for symptomatic macromastia: can predictors for operative success be identified? Plast Reconstr Surg. 1995; 95(1):77-83.
  23. Miller BJ, Morris SF, Sigurdson LL, et al. Prospective study of outcomes after reduction mammaplasty. Plast Reconstr Surg. 2005; 115(4):1025-1031.
  24. Mosteller RD. Simplified calculation of body-surface area. N Engl J Med. 1987; 317(17):1098.
  25. Netscher DT, Meade RA, Goodman CM, et al. Physical and psychosocial symptoms among 88 volunteer subjects compared with patients seeking plastic surgery procedures to the breast. Plast Reconstr Surg. 2000; 105(7):2366-2373.
  26. Saariniemi KM, Keranen UH, Salminen-Peltola PK, Kuokkanen HO. Reduction mammaplasty is effective treatment according to two quality of life instruments. A prospective randomised clinical trial. J Plast Reconstr Aesthet Surg. 2008; 61(12):1472-1478.
  27. Sadove R. New observations in liposuction-only breast reduction. Aesthetic Plast Surg. 2005; 29(1):28-31.
  28. Schnur PL, Hoehn JG, Ilstrup DM, et al. Reduction mammaplasty: cosmetic or reconstructive procedure? Ann Plast Surg. 1991; 27(3): 232-237.
  29. Schnur PL, Schnur DP, Petty PM, et al. Reduction mammaplasty: an outcomes study. Plast Reconstr Surg. 1997; 100(4):875-883.
  30. Seitchik MW. Reduction mammaplasty: criteria for insurance coverage. Plast Reconstr Surg. 1995; 95(6):1029-1032.
  31. Sood R, Mount DL, Coleman JJ 3rd, et al. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. Plast Reconstr Surg. 2003; 111(2):688-694.
  32. Wagner DS, Alfonso DR. The influence of obesity and volume of resection on success in reduction mammaplasty: an outcomes study. Plast Reconstr Surg. 2005; 115(4):1034-1038.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Society of Plastic Surgeons. Reduction mammaplasty Recommended Criteria for Third–Party Payer Coverage from the American Society of Plastic Surgeons (ASPS). May 2011. Available at: http://www.plasticsurgery.org/Medical_Professionals/Health_Policy_and_Advocacy/Health_Policy_Resources/Recommended_Insurance_Coverage_Criteria.html. Accessed on January 09, 2014.
  2. American Society of Plastic Surgeons. Reduction Mammaplasty Practice Guidelines. May 2011. Available at:  http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Reduction%20Mammaplasty_%20Evidence%20Based%20Guidelines_v5.pdf. Accessed on January 09, 2014.
  3. Kalliainen LK; ASPS Health Policy Committee. ASPS clinical practice guideline summary on reduction mammaplasty. Plast Reconstr Surg. 2012; 130(4):785-789.
Web Sites for Additional Information
  1. American Academy of Orthopaedic Surgeons. Thoracic Outlet Syndrome. Last reviewed January 2011. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=A00336&webid=23DDE252. Accessed on January 09, 2014.
  2. National Institute of Neurological Disorders and Stroke. NINDS thoracic outlet syndrome information page. Last reviewed December 2011. Available at: http://www.ninds.nih.gov/health_and_medical/disorders/thoracic_doc.htm. Accessed on January 09, 2014.
Index

Mammaplasty
Mammoplasty
Reduction Mammaplasty

Document History

Status

Date

Action

Reviewed02/13/2014Medical Policy & Technology Assessment Committee (MPTAC) review. Rationale and Reference sections updated.
Revised02/14/2013MPTAC review. Position statement updated to indicate that appropriate amounts (in grams) of breast tissue must be anticipated for removal from at least one breast. Description, Rationale and Reference sections updated.
Revised02/16/2012MPTAC review. Rationale and Reference sections updated. Note in position statement referring to physician verification form and physician verification form attachment removed.
Reviewed02/17/2011Medical Policy & Technology Assessment Committee (MPTAC) review. Rationale, Definitions and References updated.
Reviewed02/25/2010MPTAC review. Notes in position statement and physician verification form clarified. Rationale and references updated.
Reviewed02/26/2009MPTAC review. Reference links updated.
Reviewed11/20/2008MPTAC review. Rationale and references updated.
Reviewed08/28/2008MPTAC review. Rationale and references updated. Coding updated with 10/01/2008 ICD-9 changes.
 02/21/2008The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." The phrase "cosmetic/not medically necessary" was clarified to read "cosmetic and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
Reviewed08/23/2007MPTAC review. Formatting and grammar changes for clarification. References and coding updated.
 08/21/2007Updated link to BSA calculator.
 02/22/2007Added cross-reference to SURG.00085 Mastectomy for Gynecomastia in Description.
Reviewed09/14/2006MPTAC review. References updated.
Revised09/22/2005MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
   
Pre-Merger Organizations

Last Review Date

Document Number

Title

 

Anthem, Inc.04/27/2004SURG.00023Breast Procedures; including Prophylactic Mastectomy; Reconstructive Surgery, including implants; Reduction Mammaplasty; Mastectomy for Gynecomastia
WellPoint Health Networks, Inc.06/24/2004Clinical GuidelineBreast Reduction (Reduction Mammoplasty)
 06/24/2004Clinical GuidelineBreast Reduction (Continued Stay Review)

 

Appendix:

Minimum Weight of Breast Tissue Removed, per Breast, as a Function of Body Surface Area

Schnur Sliding Scale

Body Surface Area

(meters squared)

Minimum weight of tissue to be removed per breast (grams)

1.35

199

1.40

218

1.45

238

1.50

260

1.55

284

1.60

310

1.65

338

1.70

370

1.75

404

1.80

441

1.85

482

1.90

527

1.95

575

2.00

628

2.05

687

2.10

750

2.15

819

2.20

895

2.25

978

2.30 or greater

>= 1000