Breast Reduction Mammoplasty Female Medical Necessity Criteria Commercial Members

Northwest Region Utilization Review

UR 20.1 Breast Reduction (Mammoplasty) Female

Medical Necessity Criteria: Commercial Members

Department: Surgery

Section: Plastic Surgery

Applies to: KPNW Region

Review Responsibility: UROC

Subject Matter Experts: Jennifer Murphy, MD;

Patricia Sandholm, MD; H. Jonathan Chong, MD

(Plastic Surgery)

Number: UR 20.1

Effective: 2/00

Last Reviewed: 2/20, 2/20/24

Last Revised: 2/21, 3/22, 2/23

MEDICAL NECESSITY CRITERIA AND OTHER REQUIREMENTS FOR FEMALE REDUCTION MAMMOPLASTY

FOR COMMERCIAL LINES OF BUSINESS

Medical necessity criteria are applied only after member eligibility and benefit coverage is determined.

Questions concerning member eligibility and benefit coverage need to be directed to Membership Services.

Note that separate policies/criteria exist, when applicable, for coverage of:

1. Breast Reconstruction (UR 20.6)

2. Gender-Affirming Procedures (UR 65)

DEFINITIONS

See the Evidence of Coverage (EOC) as definitions of Cosmetic Services may vary within the Exclusions

section of the EOC documents.

POLICY AND CRITERIA

For Medicare Members

Source Policy

CMS Coverage Manuals Medicare Benefit Policy Manual Chapter 16-120

“Cosmetic Surgery”

National Coverage Determinations (NCD)

None

Local Coverage Determinations (LCD) LCD L37020 “Plastic Surgery”

Local Coverage Article A57222 Billing and Coding: Plastic Surgery

Kaiser Permanente Medical Policy For Medicare lines of business, apply the criteria in

the LCD.

For Non-Medicare Members

A. CRITERIA FOR BREAST REDUCTION/PLASTIC SURGERY CONSULTATION

Relevant history and physical findings must establish medical necessity, including all of the following:

1. The member must have two or more of the following conditions present for at least 6 months, with

documented failed therapeutic measures i.e. weight loss strategies, supportive garments, and

dermatologic measures:

a. Upper back pain, from breast size

b. Persistent breast pain (not relieved with hormonal adjustments or analgesics)

c. Rash under breast (unresolved with dermatologic therapies)

d. Painful bra strap grooves

e. Shoulder pain from breast size

f. Neck pain from breast size

g. Arm pain from breast size

2. Breast size D cup bra size or above.

3. Body Mass Index (BMI) less than or equal to 34.

4. Must have a normal mammogram within the past year in women 40 years or older.

5. Members with a history of tobacco products* use must have:

a. a documented “quit” date >6 months prior to referral for consultation, or

b. a negative urine anabasine test (level below 3 ng/dl) within the last 30 days if quit <6 months prior

to referral for consultation.

*tobacco products: cigarettes, cigars, pipe tobacco, e-cigarettes, smokeless tobacco (chewing tobacco and snuff).

B. CRITERIA FOR BREAST REDUCTION SURGERY (POST-CONSULTATION).

In addition to pre-consultation criteria (section A), the following must be met:

1. Predicted removal of the following:

a. minimum of 200 grams of breast tissue from the larger of the two breasts when BMI is <25.

b. minimum of 250 grams of breast tissue from the larger of the two breasts when BMI 25-30.

c. minimum of 450 grams of breast tissue from the larger of the two breasts when BMI is >30.

2. Body Mass Index (BMI) less than or equal to 34.

3. Must have a normal mammogram within the past year in women 40 years or older.

4. No diagnosis of diabetes mellitus or diabetes mellitus with A1c <8.0 within the last 3 months.

5. Members with a history of tobacco products* use must have:

a. a documented “quit” date >6 months prior to consideration for surgery, or

b. a negative urine anabasine test (level below 3 ng/dl) within the last 30 days if quit <6 months prior

to consideration for surgery.

*tobacco products: cigarettes, cigars, pipe tobacco, e-cigarettes, smokeless tobacco (chewing tobacco and snuff).

CONTRAINDICATIONS (TO BE DETERMINED BY THE SURGEON)

1. Nicotine use, including tobacco products* and nicotine replacement therapy (NRT) products** within

the 30 days prior to surgery.

*tobacco products: cigarettes, cigars, pipe tobacco, e-cigarettes, smokeless tobacco (chewing tobacco and snuff).

**NRT products: nicotine gum, lozenges, sublingual tablets, transdermal patch, nasal spray, inhaler.

2. Uncontrolled diabetes as indicated by a HbA1c of 8.0 or higher. Members with a HbA1c in the 7-8

range may be assessed for relative contraindications on a case-by-case basis.

3. Obesity is also a risk factor for poor surgical outcome. Members who are obese but otherwise meet

the above medical necessity criteria will be assessed on a case-by-case basis.

4. Any other surgical contraindications will be determined by the surgeon.

SPECIAL GROUP CONSIDERATIONS

Policy applies to all Commercial groups

This policy does not apply to OR or WA Medicaid

This policy does not apply to Medicare (see Medicare Plastic Surgery LCD 37020)

RATIONALE

EVIDENCE BASIS

Reduction Mammoplasty:

Recent systematic reviews have investigated the benefits and harms of reduction mammoplasty in individuals with

macromastia and consistently report improved outcomes among those who received reduction mammoplasty

compared to those who did not. A 2021 systematic review of randomized controlled trials reports a significant

improvement in health-related quality of life (HRQoL) at 4-6 months post-procedure among participants with

macromastia who had reduction mammoplasty compared to participants who had non-surgical interventions.

Another 2021 review of the risks and benefits of reduction mammoplasty to treat breast hypertrophy reports

improved HRQoL and a significant reduction in pain after reduction mammoplasty.

A 2020 systematic review

reports an overall statistically significant improvement in back pain following reduction mammoplasty among

patients with macromastia.

A 2019 systematic review of the effect of reduction mammoplasty on the spine of

patients with breast hypertrophy reports a substantial reduction in pain among those who underwent reduction

mammoplasty compared to those who did not.

A 2019 systematic review of patient-reported outcomes following

reduction mammoplasty indicates an overall satisfaction rate of 90.3% among patients with macromastia whose

satisfaction was directly measured following the procedure.

The underlying body of evidence included in these

reviews had some methodological limitations that hinders determinations related to patient selection for reduction

mammoplasty. One review noted that studies on reduction mammoplasty for breast hypertrophy don’t report a

definition for breast hypertrophy or detail the indications for reduction mammoplasty that were used.

Tobacco Use

A 2018 systematic review of the effect of smoking on post-operative outcomes in patients who had common

elective procedures in plastic surgery reports that tobacco use was associated with a significant increase in the total

number of post-operative complications following reduction mammoplasty.

These complications include skin

necrosis, infection, wound separation, delayed wound healing and need for reoperation, all of which were

significantly more common among smokers compared to non-smokers.

REFERENCES

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Mammaplasty: A Systematic Review and Meta-Analysis. Ann Plast Surg. Jul 1 2021;87(1):107-112.

doi:10.1097/sap.0000000000002609

2. Widmark-Jensen E, Bernhardsson S, Eriksson M, et al. A systematic review and meta-analysis of risks and

benefits with breast reduction in the public healthcare system: priorities for further research. BMC Surg. Sep 11

2021;21(1):343. doi:10.1186/s12893-021-01336-7

3. Mian S, Dyson E, Ulbricht C. Reduction mammoplasty and back pain: a systematic review and meta-analysis.

Eur Spine J. Mar 2020;29(3):497-502. doi:10.1007/s00586-019-06155-2

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mammaplasty, Annals of Plastic Surgery, 56 (2): 111-115

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