Reduction mammoplasty is considered a covered service when one of the following physical findings is present and documented in the medical record:

 

Frontal and lateral view photographs showing macromastia should be available for review in the patient's chart.

 

Minimum proposed specimen weights (both breasts combined) (glandular tissue) should be 0.4 kg for women weighing less the 60 kg (132#), 0.7 kg for women weighing 60-80 kg (132-176#), and 1 kg for women weighing more than 80 kg (176#).

 

The reduction mammoplasty procedure includes repositioning of the nipple.  

 

Diagnostic mammography meets primary coverage criteria for effectiveness and is covered prior to surgery for women:

 

Asymmetry of the breasts, intertrigo responsive to conservative therapy, ptosis of the breasts, poorly fitting clothing, or unacceptable appearance are not valid reasons for coverage for reduction mammoplasty, except for surgery on the contralateral breast following mastectomy.

 

Liposuction alone to perform this surgery is considered cosmetic and not covered.  Cosmetic services are an exclusion in the member benefit contract.

A search of the literature based on the MEDLINE database was performed for the period of 1995 to 2002. While the literature search identified several articles that discuss the surgical technique of reduction mammaplasty and document that reduction mammaplasty is associated with a relief of physical and psychosocial symptoms, the medical policy has always focused on the distinction of whether the proposed reduction mammaplasty is medically necessary or cosmetic in nature. For some patients the presence of medical indications is clear-cut, i.e., a clear documentation of recurrent intertrigo, or ulceration secondary to shoulder grooving. However, for the majority of patients, the documentation between a cosmetic and medically necessary procedure will be unclear and subjective in nature. Criteria for medically necessary reduction mammaplasty are not well addressed in the published medical literature, and thus the optimal patient selection criteria cannot rely on an evidence-based approach. Therefore, the policy guidelines do not endorse a particular set of patient selection criteria, i.e. the use of photographs, amount of breast tissue removed, or a combination of approaches.

 

The following discussion focuses the published literature addressing the use of weight of excised breast as coverage criteria. In 2001, Krieger and colleagues reported on a survey of managed care policies regarding reduction mammaplasty.  Most of the respondents to the survey stated that they use weight of excised tissue as the main criterion for allowing the procedure. The average cut-off value for this determination was 472 g. While 500 g. appears to be a commonly cited cut-off weight of excised tissue, there appears to be no documentation in the literature as to the sensitivity and specificity of this value in distinguishing cosmetic from medically necessary procedures.  Also, the use of a single weight cut-off does not address the issue of the relationship between body surface area and weight of excised tissue. In 1991, Schnur and colleagues, at the request of third party payors, developed a sliding scale.  This sliding scale was based on survey responses of 92 of 200 solicited plastic surgeons, who reported the height, weight, and amount of breast tissue removed from each breast from the last 15 to 20 reduction mammaplasties that had been performed. The surgeons were also asked if the procedure 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 according to the 5th percentile and 22nd percentile lines. Based on their estimates, those with breast weight above the 22 percentile line likely had the procedure performed for medical reasons, while those below the 5 percentile line likely had the procedure performed for cosmetic reasons, and those falling between the lines had the procedure formed for mixed reasons.

 

In 1999, Schnur reviewed the experience of the sliding scale as a coverage criterion, and reported that while many payors had adopted this scale, many had also misused it.  The author pointed out that if a payor uses weight of resected tissue as a coverage criteria, then if the weight falls below the 5th percentile line the reduction mammaplasty would be considered cosmetic, above the 22nd percentile line would be considered medically necessary, and those that fell between these lines would be considered on a case by case basis. The author also questions the frequent requirement that a woman be within 20% of her ideal body weight. While weight loss might indeed relieve symptoms, durable weight loss is notoriously difficult and may be unrealistic in many cases.

 

 

 

 

Beraldo and colleagues reported trial of 60 patients randomized to receive either reduction mammaplasty or no operation (Beraldo, 2014). The outcomes of this study were sexual function and depressive symptoms. At 6 months, Female Sexual Function Index scores were higher in the reduction mammaplasty group (27.5 vs 22.5, p<0.001). Level of depression as measured by the Beck Depression Inventory was lower in the reduction mammaplasty group (7.2 vs 13.7, p=0.01). Analyses using categories of sexual function or depression showed similar results.

 

 

In 2016, Hernanz and colleagues 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 (Hernanz, 2016). 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<0.001), with differences in 5 of the 8 subscales. At 18 months postprocedure, there was no significant difference in any SF-36 subscores except the body pain subscale between patients who had undergone reduction mammoplasty and age-matched controls.