MEDICAL POLICY - BREAST REDUCTION FOR BREAST-RELATED SYMPTOMS

Medical Policy

Joint Medical Policies are a source for BCBSM and BCN medical policy information only. These documents

are not to be used to determine benefits or reimbursement. Please reference the appropriate certificate or

contract for benefit information. This policy may be updated and is therefore subject to change.

*Current Policy Effective Date: 9/1/24

(See policy history boxes for previous effective dates)

Title:

Breast Reduction for Breast-Related Symptoms

Description/Background

MACROMASTIA

Macromastia, or gigantism, is a condition that describes breast hyperplasia or hypertrophy.

Macromastia may result in clinical symptoms such as shoulder, neck, or back pain, or recurrent

intertrigo in the mammary folds. Also, macromastia may be associated with psychosocial or

emotional disturbances related to the large breast size.

Juvenile Breast Hypertrophy

Juvenile (or virginal) breast hypertrophy is a rare, incapacitating condition where rapid and

continued breast growth occurs during puberty. It is often defined as a six-month period of

extreme breast enlargement, superseded by a longer period of slower, but sustained breast

growth. This enlargement may be unilateral or bilateral and can occur at any time during

puberty.

Treatment

Breast reduction (also referred to as reduction mammaplasty) is a surgical procedure designed

to remove a variable proportion of breast tissue to address emotional and psychosocial issues

and/or relieve the associated clinical symptoms.

While literature searches have identified many articles that discuss the surgical technique of

breast reduction and have documented that breast reduction is associated with relief of physical

and psychosocial symptoms,

2-10

an important issue is whether breast reduction is a functional

need or cosmetic. For some patients, the presence of medical indications is clear-cut: a clear

documentation of recurrent intertrigo or ulceration secondary to shoulder grooving. For some

patients, the documentation differentiating between a cosmetic and a medically necessary

procedure will be unclear. Criteria for medically necessary breast reduction are not well-

addressed in the published medical literature.

Some protocols on the medical necessity of breast reduction are based on the weight of

removed breast tissue. The basis of weight criteria is not related to the outcomes of surgery, but

to surgeons retrospectively classifying cases as cosmetic or medically necessary. Schnur et al

(1991), at the request of third-party payers, developed a sliding scale.

This scale was based

on survey responses from 92 of 200 solicited plastic surgeons, who reported the height, weight,

and amount of breast tissue removed from each a breast from the last 15 to 20 reduction

mammaplasties they had performed. Surgeons were also asked if the procedures were

performed for cosmetic or medically necessary reasons. The data were then used to create a

chart relating the body surface area and the cutoff weight of breast tissue removed that

differentiated cosmetic and medically necessary procedures. Based on their estimates, those

with a breast tissue removed weight above the 22nd percentile likely had the procedure for

medical reasons, while those below the 5th percentile likely had the procedure performed for

cosmetic reasons; those falling between the cut points had the procedure performed for mixed

reasons.

Schnur (1999) reviewed use of the sliding scale as a coverage criterion and reported that, while

many payers had adopted it, many had also misused it.

Schnur pointed out that if a payer

used weight of resected tissue as a coverage criterion, then if the weight fell below the 5th

percentile, the breast reduction would be considered cosmetic; if above the 22nd percentile, it

would be considered medically necessary; and if between these cut points, it would be

considered on a case-by-case basis. Schnur also questioned the frequent requirement that a

woman be within 20% of her ideal body weight. While weight loss might relieve symptoms,

durable weight loss is notoriously difficult and might be unrealistic in many cases.

Regulatory Status:

Breast reduction is a surgical procedure and, as such, is not subject to regulation by the U.S.

Food and Drug Administration.

Medical Policy Statement

The safety and effectiveness of breast reduction have been established. It may be considered

a useful therapeutic option (and not considered cosmetic) when:

• Individual selection guidelines in this policy are met, or

• Performed in conjunction with medically necessary breast reconstruction for the purposes

of attaining breast symmetry*

*Refer to the medical policy “Reconstructive Breast Surgery / Management of Implants”

Inclusionary and Exclusionary Guidelines

PATIENT SELECTION GUIDELINES

Patients under the age of 18 years cannot give legal consent for surgery. The parent or

legal guardian must support and authorize a reduction mammaplasty (breast reduction).

Emancipated minors may be extended individual consideration.

Inclusions:

*** Must meet A, OR must meet both B and C ***

A. Must meet both 1 and 2:

1. Patient’s breasts are fully grown (ie, breast size stable for approximately one year)

2. Removal of more than 500 grams of tissue from each breast

Must meet both B and C:

B. One of the following (1 or 2 or 3) must be met:

1. Pain

a. Documented pain in the neck and/or shoulders or postural backache which must be

of long-standing duration, AND

b. Failure of conservative therapy (eg, an appropriate support bra, exercises, heat/cold

treatments, non-steroidal anti-inflammatory agents or muscle relaxants)

2. Shoulder grooving

3. Recurrent intertrigo between the breasts and the chest wall

AND

C. Both of the following criteria must be met:

1. Individuals breasts are fully grown (ie, breast size stable for approximately one year)

2. The amount of tissue to be removed from each breast must be greater than or equal to

the 22nd percentile on the Schnur Scale.*

*If one breast meets the tissue amount based on the Schnur Scale, (even if the other

breast does not), this criterion is met.

If one breast meets the Schnur scale criteria, and all other criteria for breast reduction are met;

breast tissue may be removed from the other breast in order to achieve symmetry.

The Schnur Sliding Scale (see below) is used by physicians to evaluate individuals being

considered for breast reduction surgery.

Body surface area, along with average weight of breast tissue removed is incorporated into the

chart. If the individual's body surface area and weight of breast tissue removed fall below the

22nd percentile, then the surgery is not medically necessary. If the individual's body surface

area and weight of breast tissue removed is above the 22nd percentile, then the surgery is

considered medically necessary if other applicable criteria are met.

*Calculation of Body Surface Area

Body surface area = the square root of height (cm) times weight (kg) divided by 3600.

To convert pounds to kilograms, multiply pounds by 0.45.

To convert inches to meters, multiply inches by .0254.

To calculate body surface area (BSA) see:

< http://www-users.med.cornell.edu/~spon/picu/calc/bsacalc.htm >

Schnur Sliding Scale

Body Surface Area

(in meters squared)*

Lower 22

percentile

(Grams to be removed

per breast)

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

Exclusions:

Breast reduction is not covered for either of the following indications because it is considered

cosmetic in nature and not medically necessary:

• Surgery is being performed to treat psychological symptomatology or psychosocial

complaints, in the absence of significant physical, objective signs.

• Surgery is being performed for the sole purpose of improving appearance.

CPT/HCPCS Level II Codes (Note: The inclusion of a code in this list is not a guarantee of

coverage. Please refer to the medical policy statement to determine the status of a given procedure)

Established codes:

19318

Other codes (investigational, not medically necessary, etc.):

N/A

Note: Individual policy criteria determine the coverage status of the CPT/HCPCS code(s)

on this policy. Codes listed in this policy may have different coverage positions (such as

established or experimental/investigational) in other medical policies.

Rationale

Evidence reviews assess the clinical evidence to determine whether the use of a technology

improves the net health outcome. Broadly defined, health outcomes are length of life, quality of

life, and ability to function, including benefits and harms. Every clinical condition has specific

outcomes that are important to patients and to managing the course of that condition.

Validated outcome measures are necessary to ascertain whether a condition improves or

worsens; and whether the magnitude of that change is clinically significant. The net health

outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome

of a technology, 2 domains are examined: the relevance and the quality and credibility. To be

relevant, studies must represent 1 or more intended clinical use of the technology in the

intended population and compare an effective and appropriate alternative at a comparable

intensity. For some conditions, the alternative will be supportive care or surveillance. The

quality and credibility of the evidence depend on study design and conduct, minimizing bias

and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is

preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be

adequate. RCTs are rarely large enough or long enough to capture less common adverse

events and long-term effects. Other types of studies can be used for these purposes and to

assess generalizability to broader clinical populations and settings of clinical practice.

BREAST REDUCTION FOR MACROMASTIA - EFFICACY IN REDUCING SYMPTOMS

Clinical Context and Therapy Purpose

The purpose of breast reduction (also referred to as reduction mammaplasty) is to provide a

treatment option that is an alternative to or an improvement on existing therapies, such as

nonsurgical treatment, in individuals with symptomatic macromastia.

The following PICO was used to select literature to inform this review.

Populations

The relevant population of interest is individuals with symptomatic macromastia, or

gigantomastia, a condition that describes breast hyperplasia or hypertrophy.

Interventions

The therapy being considered is breast reduction, a surgical procedure that removes a variable

proportion of breast tissue to relieve the associated clinical symptoms and address emotional

and psychosocial issues related to large breast size.

Comparators

Comparators of interest include nonsurgical treatment which primarily involves analgesia,

clothing modifications, physical therapy and other measures to address symptoms.

Outcomes

The general outcomes of interest are symptoms and functional outcomes. Symptoms of

symptomatic macromastia can include mastalgia, pain in the shoulders, back, and neck, and

recurrent intertrigo in the mammary fold. The condition may also be associated with

psychosocial or emotional disturbances.

Study Selection Criteria

Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a

preference for RCTs;

• In the absence of such trials, comparative observational studies were sought, with a

preference for prospective studies.

• To assess longer term outcomes and adverse events, single-arm studies that capture

longer periods of follow-up and/or larger populations were sought.

• Studies with duplicative or overlapping populations were excluded.

Review of Evidence

Randomized Controlled Trials

Sabino Neto et al (2008) assessed functional capacity for 100 patients, ages 18 to 55 years,

who were randomized to reduction mammaplasty or to waiting list control.

Forty-six patients

from each group completed the study. At baseline and 6 months later, patients were assessed

for functional capacity using the Roland-Morris Disability Questionnaire (0=best performance,

24=worst performance) and for pain using a visual analog scale (VAS). The breast reduction

mammaplasty group showed improvement in functional status, with an average score of 5.9

preoperatively and 1.2 within 6 months postoperatively (p<.001 for pre-post comparison within

the mammaplasty group) versus an unchanged average score of 6.2 in the control group on

the first and second evaluations. Additionally, pain in the lower back decreased on the VAS

from an average of 5.7 preoperatively to 1.3 postoperatively (p<.001 for pre-post comparison

within the mammaplasty group) versus VAS average scores in the control group of 6.0 and 5.3

on the first and second evaluations, respectively (p=not significant).

Saariniemi et al (2008) reported on the quality of life (QOL) and pain in 82 patients randomized

to reduction mammaplasty or a nonoperative group and evaluated at baseline and 6 months

later.

The authors reported that the mammaplasty group had significant improvements in

QOL from baseline to 6 months, as measured by the Physical Component Summary score of

the 36-Item Short-Form Health Survey (SF-36; change, +9.7 vs +0.7, p<.001), the Utility Index

score (SF-6D; change, +17.5 vs +0.6), the index score of QOL (SF-15D; change, +8.6 vs

+0.06, p<.001), and SF-36 Mental Component Summary score (change, +7.8 vs -1.0, p<.002).

There were also improvements in breast-related symptoms from baseline to 6 months, as

measured by Finnish Breast-Associated Symptoms questionnaire scores (-47.9 vs -3.5,

p<.001), and Finnish Pain Questionnaire scores (-21.5 vs -1.0, p<.001).

Iwuagwu et al (2006) reported on 73 patients randomized to reduction mammaplasty within 6

weeks or after a 6-month waiting period to assess lung function.

All patients had symptoms

related to macromastia. Postoperative lung function correlated with the weight of breast tissue

removed, but there were no significant improvements in any lung function parameters for the

mammaplasty group compared with the control group.

Key trials are reported in Tables 1 and 2 below.

Table 1. Summary of Key Randomized Controlled Trial Characteristics

Study; Trial

Countries

Sites

Dates

Participants

Interventions

Active

Comparator

Sabino Neto (2008)

Brazil

2002-2004

Female patients (age 18 to

55 yrs) with breast

hypertrophy (n=100)

Reduction

mammaplasty

(n=50)

Waiting list control

(n=50)

Saariniemi (2008)

Finland

Female patients with

symptomatic breast

hypertrophy (n=82)

Reduction

mammaplasty

(n=40)

Non-operative

control

(n=42)

NR: not reported

Table 2. Summary of Key Randomized Controlled Trial Results

Study

Change (Pre- to

Postoperative)

in RSES

Change (Pre- to

Postoperative)

in RMDQ

Change (Pre- to

Postoperative)

in VAS

Change (Pre- to

Postoperative)

in SF-36 Utility

Index Score

Change (Pre- to

Postoperative)

in Mental

Summary Score

Change (Pre- to

Postoperative)

in Pain Score

Sabino Neto

(2008)

Mammaplasty

8.9 to 4.9

(p<0.001)

5.9 to 1.2

(p<0 001)

5.7 to 1.3

(p<0.001)

Control

9.1 to 9.0

(p>0.999)

6.2 to 6.2 (NR)

6.0 to 5.3

(p<0.001)

Saariniemi

(2008)

Mammaplasty

0.645 to 0.820

46.0 to 53.8

28.5 to 7.0

Control

0.657 to 0.663

47.2 to 46.2

27.5 to 26.5

P-value

<0.001

<0.002

<0.001

RSES: Rosenberg Self-Esteem Scale; RMDQ: Roland-Morris Disability Questionnaire; VAS: visual analog scale; NR: Not

reported

The purpose of the limitations tables (Table 3 and 4) is to display notable limitations identified

in each study. This information is synthesized as a summary of the body of evidence following

each table and provides the conclusions on the sufficiency of evidence supporting the position

statement.

Table 3. Study Relevance Limitations

Study

Population

Intervention

Comparator

Outcomes

Duration of

-up

Sabino Neto

(2008)

3. Comparator group on waiting list

without additional intervention

described

5. Clinical significant

difference not

prespecified

Saariniemi

(2008)

3. Comparator group did not receive

surgery and had no other

intervention described

5. Clinical significant

difference not

prespecified

The study limitations stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.

a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study

population not representative of

intended use.

b Intervention key: 1. Not clearly defined; 2. Version used unclear; 3. Delivery not similar intensity as comparator; 4.Not the

intervention of interest.

c Comparator key: 1. Not clearly defined; 2. Not standard or optimal; 3. Delivery not similar intensity as intervention; 4. Not

delivered effectively.

d Outcomes key: 1. Key health outcomes not addressed; 2. Physiologic measures, not validated surrogates; 3. No CONSORT

reporting of harms; 4. Not

established and validated measurements; 5. Clinical significant difference not prespecified; 6. Clinical significant difference not

supported.

e Follow-Up key: 1. Not sufficient duration for benefit; 2. Not sufficient duration for harms.

Table 4. Study Design and Conduct Limitations

Study

Allocation

Blinding

Selective

Reporting

Follow-Up

Power

Statistical

Sabino Neto

(2008)

1,2,3. No

blinding

3. Some p-values

not reported

Saariniemi

(2008)

1,2,3. No

blinding

1. 22% of patients

lost to follow-up

The evidence gaps stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.

a Allocation key: 1. Participants not randomly allocated; 2. Allocation not concealed; 3. Allocation concealment unclear; 4.

Inadequate control for selection bias.

b Blinding key: 1. Not blinded to treatment assignment; 2. Not blinded outcome assessment; 3. Outcome assessed by treating

physician.

c Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.

d Follow-Up key: 1. High loss to follow-up or missing data; 2. Inadequate handling of missing data; 3. High number of

crossovers; 4. Inadequate handling of crossovers; 5. Inappropriate exclusions; 6. Not intent to treat analysis (per protocol

e Power key: 1. Power calculations not reported; 2. Power not calculated for primary outcome; 3. Power not based on clinically

important difference.

f Statistical key: 1. Intervention is not appropriate for outcome type: (a) continuous; (b) binary; (c) time to event; 2. Intervention

is not appropriate for multiple observations per patient; 3. Confidence intervals and/or p values not reported; 4.Comparative

treatment effects not calculated.

Observational Studies

Singh and Losken (2012) reported on a systematic review of studies reporting outcomes after

reduction mammaplasty.

In 7 studies reporting on physical symptoms (n range, 11 to 92

patients), reviewers found reduction mammaplasty improved functional outcomes including

pain, breathing, sleep, and headaches. Additional psychological outcomes noted included

improvements in self-esteem, sexual function, and quality of life. Torresetti et al (2022)

conducted another systematic review to examine the potential association between bilateral

breast reduction and improvement in lung function in women with macromastia.

14,

The review

included 15 studies published from 1974 to 2018 (n range, 1 to 50 patients). The findings

showed that reduction mammaplasty can lead to changes in objective respiratory parameters,

such as spirometric tests or arterial blood gas measurements, but the clinical significance of

these changes was unclear.

Hernanz et al (2016) reported on a descriptive cohort study of 37 consecutive obese patients

who underwent reduction mammoplasty for symptomatic macromastia, along with 37 age-

matched women hospitalized for short-stay surgical procedures.

In the preoperative state,

SF-36 physical health component subscore was significantly lower for patients with

symptomatic macromastia (40) than for age-matched controls (53; P<.001), with differences in

5 of the 8 subscales. At 18 months postprocedure, there were no significant differences in any

SF-36 subscores except the body pain subscale between patients who had undergone

reduction mammoplasty and age-matched controls.

Kerrigan et al (2002) published the results of the BRAVO (Breast Reduction: Assessment of

Value and Outcomes) study, a registry of 179 women undergoing reduction mammaplasty.

Women were asked to complete quality of life questionnaires and a physical symptom count

both before and after surgery. The physical symptom count focused on the number of

symptoms present that were specific to breast hypertrophy and included upper back pain,

rashes, bra strap grooves, neck pain, shoulder pain, numbness, and arm pain. Also, the weight

and volume of resected tissue were recorded. Results were compared with a control group of

patients with breast hypertrophy, defined as size DD bra cup, and normal-sized breasts, who

were recruited from the general population. The authors proposed that the presence of 2

physical symptoms might be an appropriate cutoff for determining medical necessity for breast

reduction. For example, while 71.6% of the hypertrophic controls reported none or 1 symptom,

only 12.4% of those considered surgical candidates reported none or 1 symptom. This

observation is difficult to evaluate because the study did not report how surgical candidacy was

determined. The authors also reported that none of the traditional criteria for determining

medical necessity for breast reduction surgery (height, weight, body mass index , bra cup size,

or weight of resected breast tissue) had a statistically significant relation with outcome

improvement. The authors concluded that the determination of medical necessity should be

based on patients’ self-reported symptoms rather than more objectively measured criteria (eg,

weight of excised breast tissue).

Adverse Events

Thibaudeau et al (2010), conducted a systematic review to evaluate breastfeeding after

reduction mammaplasty.

After a review of literature from 1950 through 2008, reviewers

concluded that reduction mammaplasty does not reduce the ability to breastfeed. In women

who have had reduction mammaplasty, breastfeeding rates were comparable in the first month

postpartum to rates in the general population in North America.

Chen et al (2011) reported on a review of claims data to compare complication rates after

breast surgery in 2,403 obese and ,5597 nonobese patients.

Of these patients, breast

reduction was performed in 1,939 (80.7%) in the study group and in ,3569 (63.8%) in the

control group. Obese patients had significantly more claims for complications within 30 days

after breast reduction surgery (14.6%) than nonobese patients (1.7%; p<.001). Complications

included inflammation, infection, pain, and seroma/hematoma development. Shermak et al

(2011) reported on a review of claims data comparing complication rates by age after breast

reduction surgery in 1,192 patients.

Infection occurred more frequently in patients older than

50 years of age (odds ratio , 2.7; p=.003). Additionally, women older than 50 years

experienced more wound healing problems (odds ratio, 1.6; p=.09) and reoperative wound

debridement (odds ratio, 5.1; p=.07). Other retrospective evaluations (2013, 2014) of large

population datasets have reported increased incidences of perioperative and postoperative

complications with high body mass index.

20,21

Section Summary: Breast Reduction for Macromastia-Efficacy in Reducing Symptoms

Systematic reviews, randomized trials, and observational studies have shown that several

measures of function and quality of life improve after breast reduction.

Summary of Evidence

For individuals who have symptomatic macromastia who receive breast reduction, the

evidence includes systematic reviews, randomized controlled trials, cohort studies, and case

series. Relevant outcomes are symptoms and functional outcomes. Studies have indicated

that reduction mammaplasty is effective at decreasing breast-related symptoms such as pain

and discomfort. There is also evidence that functional limitations related to breast hypertrophy

are improved after breast reduction. These outcomes are achieved with acceptable

complication rates. The evidence is sufficient to determine that the procedure results in an

improvement in the net health outcome.

Juvenile Breast Hypertrophy

Wolfswinkle et al (2013)

discussed hyperplastic breast anomalies in the adolescent, including

juvenile breast hypertrophy. The authors reviewed treatment for this rare but alarming

condition. Surgical options include reduction mammoplasty. The authors stressed that

confirmation of breast growth stabilization is recommended as surgery in the active growth

phase has been associated with recurrence of breast enlargement postoperatively.

SUPPLEMENTAL INFORMATION

The purpose of the following information is to provide reference material. Inclusion does not

imply endorsement or alignment with the evidence review conclusions.

Practice Guidelines and Position Statements

Guidelines or position statements will be considered for inclusion in ‘Supplemental Information

if they were issued by, or jointly by, a US professional society, an international society with US

representation, or National Institute for Health and Care Excellence (NICE). Priority will be

given to guidelines that are informed by a systematic review, include strength of evidence

ratings, and include a description of management of conflict of interest.

American Society of Plastic Surgeons

In 2011, the American Society of Plastic Surgeons (ASPS) issued practice guidelines and a

companion document on criteria for third-party payers for reduction mammaplasty.

22,23

This

guideline was updated and reaffiredin March 2021. Based on high quality evidence, the ASPS

strongly recommends that "postmenarche female patients presenting with breast hypertrophy

should be offered reduction mammaplasty surgery as first-line therapy over nonoperative

therapy based solely on the presence of multiple symptoms rather than resection weight." The

guideline goes on to state that "reduction mammaplasty surgery is considered standard of care

for symptomatic breast hypertrophy." The companion document notes that medical records

should document the symptoms associated with the hypertrophy the patient has experienced,

and lists the following:

• "Documentation may include pain that patient experiences in the neck, back, or breasts

related to movement

• Difficulties in daily activities such as grocery shopping, banking, using transportation,

preparing meals, feeding, showering, etc

• Documentation of any secondary complications or infections that may have occurred as

a result of hypertrophy or macromastia including intertrigo, chronic rash, cervicalgia,

dorsalgia, or kyphosis

• Documentation of prior procedures or therapies may be included but not required for

approval

• Photographs demonstrating the patient’s breast appearance, possible shoulder grooves

and kyphosis can be included in the medical documentation

• Significant scientific evidence supports non-operative therapies should not be required

prior to approval of the procedure."

U.S. Preventive Services Task Force Recommendations

Not applicable

Ongoing and Unpublished Clinical Trials

A search of ClinicalTrials.gov did not identify any ongoing or unpublished trials that would likely

influence this review.

Government Regulations

National:

There is no national coverage determination (NCD) on this topic. In the absence of an NCD,

coverage decisions are left to the discretion of the local Medicare carriers.

Local:

Wisconsin Physicians Service Insurance Corporation (WPS)

Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L39051)

Original effective date 11/14/2021 Revision 11/30/2023

[Note: following is information in the LCD that is specific to breast reduction]

Medical necessity for a breast reduction is limited to circumstances in which:

• There are signs and/or symptoms resulting from the enlarged breasts (macromastia)

that have not responded adequately to non-surgical interventions,

• To improve or correct asymmetry following cancer surgery on one breast.

Note: either the involved breast or contralateral breast may be treated to achieve

symmetry.

Note: For coverage indications for contralateral reconstruction of an unaffected breast

following a medically necessary mastectomy, refer to the CMS Internet-Only Manual,

Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2,

§140.2.

Non-surgical interventions preceding breast reduction should include as appropriate, but are

not limited to, the following:

• Determining the macromastia is not due to an active endocrine or metabolic process.

• Determining the symptoms are refractory to appropriately fitted supporting garments, or

following unilateral mastectomy, persistent with an appropriately fitted prosthesis or

reconstruction therapy at the site of the absent breast.

• Determining that dermatologic signs and/or symptoms are refractory to, or recurrent

following, a completed course of medical management.

A medically reasonable and necessary breast reduction could be indicated in the presence of

significantly enlarged breasts and the presence of at least one of the following signs and/or

symptoms:

• Back, neck or shoulder pain from macromastia and unrelieved by 6 months of:

- Conservative analgesia,

- Supportive measures (garment, etc.),

- Physical Therapy, or

• Significant arthritic changes in the cervical or upper thoracic spine, optimally managed

with persistent symptoms and/or significant restriction of activity, or

• Intertriginous maceration or infection of the inframammary skin refractory related to

dermatologic measures.

• Permanent shoulder grooving with skin irritation by supporting garment (bra strap).

The amount of breast tissue to be removed must be proportional to the body surface area

(BSA) per the Schnur18 scale below. If the individual’s body surface area and weight of breast

tissue removed fall above the 22

percentile, then the surgery is considered medically

reasonable and necessary with the appropriate criteria. If only one breast meets the Schnur

scale criteria; breast tissue may be removed from the other breast in order to achieve

symmetry.

Schnur Scale:

Body Surface

Area (m2)

Average grams of tissue per breast to

be removed

1.40

-1.50

218

-260

1.51

–1.60

261

-310

1.61

-1.70

311

-370

1.71

-1.80

371

-441

1.81

-1.90

442

-527

1.91

-2.00

528

-628

2.01

-2.10

629

-750

2.11

-2.20

751

-895

2.21

-2.30

896

-1068

2.31

-2.40

1069

-1275

2.41

-2.50

1276

-1522

2.51

-2.60

1523

-1806

2.61

-2.70

1807

-2154

2.71

-2.80

2155

-2568

2.81

-2.90

2569

-3061

2.91

-3.00

3062

-3650

Wisconsin Physicians Service Insurance Corporation (WPS)

Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L34698)

Original effective date 10/01/2015

Revision effective date 01/01/2021; Revision ending date 11/13/2021

Retirement Date 11/13/2021

(The above Medicare information is current as of the review date for this policy. However, the coverage issues

and policies maintained by the Centers for Medicare & Medicare Services [CMS, formerly HCFA] are updated

and/or revised periodically. Therefore, the most current CMS information may not be contained in this

document. For the most current information, the reader should contact an official Medicare source.)

Related Policies

• Reconstructive Breast Surgery/Management of Breast Implants

• Prophylactic Mastectomy (Retired)

References

1. Wolfswinkle EM, et al. Hyperplastic Breast Anomalies in the Female Adolescent Breast.

Semin Plast Surg. 2013 Feb; 27(1):49-55.

2. Dabbah A, Lehman JA, Jr., Parker MG et al. Reduction mammaplasty: an outcome

analysis. Ann Plast Surg 1995; 35(4):337-41. PMID 8585673

3. Schnur PL, Schnur DP, Petty PM et al. Reduction mammaplasty: an outcome study. Plast

Reconstr Surg 1997; 100(4):875-83. PMID 9290655

4. Hidalgo DA, Elliot LF, Palumbo S et al. Current trends in breast reduction. Plast Reconstr

Surg 1999; 104(3):806-15; quiz 16; discussion 17-8. PMID 10456536

5. 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; discussion 83-5. PMID 9915166

6. 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):1556-66. PMID 11932597

7. Iwuagwu OC, Walker LG, Stanley PW et al. Randomized clinical trial examining

psychosocial and quality of life benefits of bilateral breast reduction surgery. Br J Surg

2006; 93(3):291-4. PMID 16363021

8. Sabino Neto M, Dematte MF, Freire M et al. Self-esteem and functional capacity outcomes

following reduction mammaplasty. Aesthet Surg J 2008; 28(4):417-20. PMID 19083555

9. Iwuagwu OC, Platt AJ, Stanley PW et al. Does reduction mammaplasty improve lung

function test in women with macromastia? Results of a randomized controlled trial. Plast

Reconstr Surg 2006; 118(1):1-6; discussion 7. PMID 16816661

10. Saariniemi KM, Keranen UH, Salminen-Peltola PK et al. 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):1472-8. PMID 17983882

11. Schnur PL, Hoehn JG, Ilstrup DM et al. Reduction mammaplasty: cosmetic or

reconstructive procedure? Ann Plast Surg 1991; 27(3):232-7. PMID 1952749

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1999; 42(1):107-8. PMID 9972729

13. Singh KA, Losken A. Additional benefits of reduction mammaplasty: a systematic review of

the literature. Plast Reconstr Surg 2012; 129(3):562-70. PMID 22090252

14. Torresetti M, Zuccatosta L, Di Benedetto G. The effects of breast reduction on pulmonary

functions: A systematic review. J Plast Reconstr Aesthet Surg. Dec 2022; 75(12): 4335-4346.

PMID 36229312

15. Hernanz F, Fidalgo M, Munoz P, et al. Impact of reduction mammoplasty on the quality of

life of obese patients suffering from symptomatic macromastia: A descriptive cohort study.

J Plast Reconstr Aesthet Surg. Aug 2016;69(8):e168-173. PMID 27344408

16. Kerrigan CL, Collins ED, Kim HM, et al. Reduction mammaplasty: defining medical

necessity. Med Decis Making. May-Jun 2002;22(3):208-217. PMID 12058778

17. Thibaudeau S, Sinno H, Williams B. The effects of breast reduction on successful

breastfeeding: a systematic review. J Plast Reconstr Aesthet Surg. Octr 2010; 63(10):1688-

93. PMID 19692299

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reduction surgery. Plast Reconstr Surg. Dec 2011; 128(6):1182-7. PMID 22094737

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mammaplasty: a multicenter analysis of 2492 patients. Aesthet Surg J. Nov 1

2013;33(8):1140-1147. PMID 24214951

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22. American Society of Plastic Surgeons. Reduction Mammaplasty: ASPS Recommended

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https://www.plasticsurgery.org/documents/Health-Policy/Reimbursement/insurance-2021-

reduction-mammaplasty.pdf. Accessed 4/8/24

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The articles reviewed in this research include those obtained in an Internet based literature search

for relevant medical references through 4/8/24, the date the research was completed.

Joint BCBSM/BCN Medical Policy History

Policy

Effective Date

BCBSM

Signature Date

BCN

Signature Date

Comments

6/27/02 6/27/02 6/27/02 Joint policy established

7/20/04 7/20/04 6/30/04 Routine maintenance

3/23/06 3/23/06 3/23/06 Routine maintenance

7/1/08 5/17/08 5/18/08 Routine maintenance

11/1/08 8/19/08 9/23/08 Criteria updated

3/1/09 12/9/08 12/30/08 Routine maintenance, added

weight/height chart, BMI calculator

and link

9/1/10 6/15/10 6/15/10 Criteria Updated, removed BMI

calculator and link

9/1/11 6/21/11 6/21/11 Routine maintenance

7/1/13 4/16/13 4/22/13 Routine maintenance; reformatted

description, rationale and references

to mirror BCBSA.

Title changed from “Breast

Reduction Mammoplasty” to

“Reduction Mammaplasty for Breast-

Related Symptoms”.

11/1/14 8/21/14 8/25/14 Routine maintenance

7/1/16 4/19/16 4/19/16 Routine maintenance

7/1/17 4/18/17 4/18/17 Routine maintenance

7/1/18 4/17/18 4/17/18 Routine maintenance

7/1/19 6/24/19 Routine maintenance

Revision to inclusions: statement

regarding reduction mammaplasty

surgery in patients under the age of

18 years; criterion for minimum

tissue removal of 1000mg without

requirement of functional issues

changed to 500gm; clarification of

criteria under functional

issues/conservative therapies;

“breasts are fully grown” further

defined to “breast size stable over

one year”.

9/1/20 6/16/20 Routine maintenance

Changes to inclusions: only one

functional issue is required; if one

breast meets criteria per Schnur

scale, that criterion is met. If one

breast meets all criteria, other breast

may be reduced for symmetry.

Addition: description of adolescent

macromastia, Ref 23

9/1/21 6/15/21 Routine maintenance

Code 19318 was revised

Verbiage changes in title, medical

policy statement, background

section, summary from “reduction

mammaplasty” to “breast reduction”.

9/1/22 6/21/22 Routine maintenance.

9/1/23 6/13/23 Routine maintenance (jf)

Vendor managed NA

1/1/24 10/17/23

Routine maintenance (jf)

Vendor managed NA

Revision of Medical Policy Statement

Gender affirming language removed

9/1/24 6/11/24

Routine maintenance (jf)

Vendor managed NA

Next Review Date: 2nd Qtr, 2025

BLUE CARE NETWORK BENEFIT COVERAGE

OLICY: BREAST REDUCTION FOR BREAST-RELATED SYMPTOMS

Coverage Determination:

Commercial HMO

(includes Self-Funded

groups unless otherwise

specified)

Covered; policy criteria apply.

BCNA (Medicare

Advantage)

See Government Regulations section.

BCN65 (Medicare

Complementary)

Coinsurance covered if primary Medicare covers the

service.

Administrative Guidelines:

• The member's contract must be active at the time the service is rendered.

• Coverage is based on each member’s certificate and is not guaranteed. Please

consult the individual member’s certificate for details. Additional information regarding

coverage or benefits may also be obtained through customer or provider inquiry

services at BCN.

• The service must be authorized by the member's PCP except for Self-Referral Option

(SRO) members seeking Tier 2 coverage.

• Services must be performed by a BCN-contracted provider, if available, except for

Self-Referral Option (SRO) members seeking Tier 2 coverage.

• Payment is based on BCN payment rules, individual certificate and certificate riders.

• Appropriate copayments will apply. Refer to certificate and applicable riders for

detailed information.

• CPT - HCPCS codes are used for descriptive purposes only and are not a guarantee

of coverage.