Commercial
Advanced Search

Reduction Mammoplasty
11.08.02l

Policy

MEDICALLY NECESSARY
​
REDUCTION MAMMOPLASTY
Reduction mammoplasty is considered medically necessary and, therefore,​ covered for any of the following indications:
  • To correct breast asymmetry associated with a medically necessary mastectomy or lumpectomy of the contralateral breast
  • For breast hypertrophy (i.e., macromastia or gigantomastia) when ALL of the following criteria are met:
    • An appropriate amount of breast tissue will be removed such that there is a reasonable likelihood of symptomatic relief based on the individual's body surface area (BSA) and the Schnur Sliding Scale (refer to Guidelines section for Schnur Sliding Scale).
    • Breast hypertrophy is not caused by an active endocrine, pharmaceutical, or metabolic process. If an active endocrine, pharmaceutical, or metabolic process is found, breast hypertrophy ​and related symptoms persist after nonsurgical treatment (e.g., discontinuation of a known pharmaceutical agent, when medically appropriate).​
    • For adolescents, the cup size is stable (i.e., has not changed) for at least 6 months.
    • One of the following has been present for a minimum of 6 weeks​:
      • Dermatologic signs or symptoms (e.g., intertriginous maceration [intertrigo], discoloration, chronic or recurrent infection of the inframammary skin) that are refractory to or recurrent following a completed course of medical management, such as appropriately fitted supporting garments, or following unilateral mastectomy, persistent with an appropriately fitted prosthesis or reconstruction therapy at the site of the absent breast​.
      • Shoulder, neck, or back pain or significant arthritic changes in the cervical or upper thoracic spine, with persistent symptoms and/or significant limitations in activities of daily living, when both apply:
        • ​​There is reasonable likelihood that the individual's symptoms are primarily due to the size or weight of the breasts, and
        • Symptoms are unrelieved by conservative measures (e.g., support bra, exercise, heat/cold treatment, nonsteroidal anti-inflammatory drugs [NSAIDs] or muscle relaxants) or physical therapy.
      • Shoulder grooving to a depth greater than 1 cm with skin irritation or darkening that has not responded to appropriately fitted support garments.​
      • ​Documentation of ptosis with the nipple areolar complex 8 cm below the inframammary crease when accompanied by one of the above listed signs or symptoms, or by a documented functional impairment.​
  • ​For the treatment of gigantomastia of pregnancy when it is accompanied by any of the following complications (and delivery is not imminent), and signs or symptoms are refractory to medical treatment or physical interventions have not adequately alleviated symptoms:
    • Massive infection
    • Significant hemorrhage
    • Tissue necrosis with slough
    • Ulceration of the breast tissue
    • Intertriginous maceration or infection of the inframammary skin refractory to dermatologic measures
COSMETIC
All other uses for reduction mammoplasty, such as but not limited to, the sole use of liposuction for reduction mammoplasty, reduction mammoplasty performed solely to remove fat and/or skin, or when the minimum specimen weight of breast tissue does not meet the medical necessity criteria as outlined above, are considered a cosmetic service. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

NOT MEDICALLY NECESSARY

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. Upon audit, if it is determined that the service performed is not consistent with the information presented at the time of precertification approval, the service will be considered Not Medically Necessary. As such, claim retractions will occur based on a retrospective claim audit review. Providers will be notified prior to any retrospective payment retraction and be afforded the standard facility appeals review process for dispute resolution.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

All requests for reduction mammoplasty require review by the Company's cosmetic review team and must include documentation. This documentation is to include, but is not limited to: photographic confirmation of breast size; results of mammography as appropriate (e.g., when performed in conjunction with breast cancer surgery); medical records regarding previous treatment (e.g., dermatologic treatment measures for chronic or recurrent infection of the inframammary skin in individuals with macromastia); amount of breast tissue actually removed (i.e., pathology report) and other health care professional reports.

Guidelines

REDUCTION MAMMOPLASTY

The volume or weight of the potential breast tissue resection should be combined with other concurrent symptoms to determine the appropriateness of a reduction mammoplasty procedure for an individual.

The table below is an evaluation method (Schnur Sliding Scale chart) for the minimum estimated specimen weight (in grams) of breast tissue that the surgeon will remove from each breast, based on the individual's body surface area (BSA):

Simplified formula for calculation of BSA:
BSA (in m2) = [height (cm)] 0.718 × [weight (kg)] 0.427 ×​ 0.007449

See the web site for easy calculation: http://www.bcbst.com/providers/calculator.asp.

To convert weight in pounds to kilograms, multiply pounds by 0.45.

To convert height in inches to centimeters, multiply inches by 2.54.

Schnur Sliding Scale
BSA (m2)
Resected tissue weight; each breast in grams
1.40
220
1.45
240
1.50
260
1.55
285
1.60
310
1.65
340
1.70
370
1.75
405
1.80
440
1.85
480
1.90
525
1.95
575
2.00
630
2.05
685
2.10
750
2.15
820
2.20
895
2.25
980
2.30
1,070
2.35
1,165
2.40
1,275
2.45
1,395
2.50
1,520
2.55
1,660

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, reduction mammoplasty is covered under the medical benefits of the Company's products when the medical necessity criteria listed in the medical policy are met. Individual benefits must be verified.

A cosmetic service is a benefit contract exclusion for all of the Company’s products.

CROSS-REFERENCE POLICIES

For information on reduction mammoplasty to correct an asymmetry due to a congenital defect or an abnormality, refer to the policy on reconstructive breast surgery.

Refer to the Cross References section in this policy for a list of Company policies that address services related to this topic, as well as links to summaries of any applicable mandate(s).

Description

Reduction mammoplasty is a surgical procedure used to treat female breast hypertrophy (i.e., macromastia or gigantomastia). The surgery involves the excision of a portion of the breast, including the skin and underlying glandular tissue, to reduce the size, shape, and weight of mammary tissue. Macromastia is defined as a marked, abnormally excessive, pendulous enlargement of one or both breasts. This condition may result in pain of the shoulder, neck, or back, nerve compression of the arms, and recurrent intertrigo in the mammary folds. Reduction mammoplasty can also be performed to alleviate symptoms for a rare condition called gigantomastia. To date, there is no universally acceptable definition for gigantomastia, and the exact cause of gigantomastia has not yet been determined; however, it is characterized by excessive breast growth that may occur spontaneously, during puberty, pregnancy, or while taking certain medication. Although reduction mammoplasty may be done at any age, it is usually performed when breast development is complete. In select cases (e.g., when the breasts are not too large and the skin has good elasticity), liposuction has been used as a sole method of treatment to reduce the overall breast size. However, in most cases, only fat, not glandular breast tissue, can be successfully removed by liposuction.

Schnur et al. (1991) developed a sliding scale based on a survey response from plastic surgeons who recorded the height, weight, and amount of breast tissue removed from each breast during reduction mammoplasty. The surgeons were also asked if the procedures were performed for cosmetic or medically necessary reasons. The data were used to create a chart relating the body surface area (BSA) and the cut-off weight of breast tissue removed. The Schnur scale (abbreviated in the Guidelines section) allows a rough estimate of the minimal amount of soft tissue to be removed to justify surgery to alleviate symptoms based on BSA.

Kerrigan et al. (2002) published the results of the Breast Reduction: Assessment of Value and Outcomes (BRAVO) study, a registry of 179 women undergoing reduction mammoplasty. The participating women were asked to complete questionnaires addressing quality of life and physical symptoms both before and after surgery. The physical symptom evaluation focused on the number of symptoms that were specific to breast hypertrophy such as back pain, rashes, bra strap grooves, neck pain, shoulder pain, numbness, and arm pain. In addition, the weight and volume of resected breast tissue was documented. The results were compared with a control group of individuals with either breast hypertrophy or normal size breasts who were recruited from the general population. The authors proposed that the presence of at least two physical symptoms should be appropriate for determining medical necessity for breast reduction. The authors reported that while 71.6% of the hypertrophic control group reported zero or one symptom, only 12.4% of the surgical candidates reported zero or one symptom. This observation was 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 (e.g., height, weight, body mass index, bra cup size, or weight of resected tissue) had a statistically significant relationship with postsurgical symptom improvement. The authors concluded that the determination of medical necessity should be based on the individual's report of symptoms rather than more objectively measured criteria, such as estimated weight of excised breast tissue.

Iwuagwu et al. (2006a) reported on 73 individuals randomly assigned to reduction mammoplasty within 6 weeks or after a 6-month waiting period to assess lung function. All individuals 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 mammoplasty group compared with the control group.
In 2008, a ​randomized controlled trial by Sabino Neto et al. assessed functional capacity of 100 individuals. Subjects were randomly assigned to reduction mammoplasty or waiting list control. At the onset of study and 6 months later, individuals 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 reduction mammoplasty group showed improvement in functional status, with an average score of 5.9 preoperatively to 1.2 within 6 months postoperatively (P<0.001 for pre-post comparison within the mammoplasty group) versus an unchanged average score of 6.2 in control group on the first and second evaluations. Subjects in the reduction mammoplasty group also reported decrease in pain in the lower back region on the VAS from an average of 5.7 preoperatively to 1.3 postoperatively (P<0.001 for pre-post comparison within the mammoplasty group) versus VAS average score in the control group of 6.0 and 5.3 on the first and second evaluations, respectively (no significant change).

Also in 2008, Saariniemi et al. reported on quality of life (QOL) and pain in 82 individuals who were randomly assigned to reduction mammoplasty or a nonoperative group and evaluated at baseline and 6 months later. At 6 months, the authors reported that the mammoplasty group had significant improvement in QOL as measured by physical component summary score of the 36-Item Short-Form Health Survey (SF-36; change, +9.7 vs +0.7; P<0.001), 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<0.001), and SF-36 mental component summary score (change, +7.8 vs −1.0; P<0.002). The authors also reported improvements in breast-related symptoms, as reported by the Finnish Breast-Associated Symptoms questionnaire score and the Finnish Pain questionnaire score (−47.9 vs −3.5, P<0.001; 21.5 vs −1.0; P<0.001, respectively).

Thibaudeau et al. (2010) conducted a systematic review to evaluate breastfeeding after reduction mammoplasty. After a review of literature from 1950 through 2008, the reviewers concluded that reduction mammoplasty does not reduce the ability to breastfeed. In women who had reduction mammoplasty, 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 2403 obese and 5597 nonobese individuals. Of these individuals, breast reduction was performed in 1939 (80.7%) in the study group and 3569 (63.8%) in the control group. Obese individuals had significantly more claims for complications within 30 days after breast reduction surgery (14.6%) than nonobese individuals (1.7%; P<0.001). Complications included inflammation, infection, pain, and seroma/hematoma development.

Shermak et al. (2011) also reported on a review of claims data comparing complication rates by age after breast reduction surgery in 1192 individuals. Infection occurred more frequently in individuals older than 50 years of age (odds ratio [OR], 2.7; P=0.003). Additionally, women older than 50 years experienced more wound healing problems (OR, 1.6; P=0.09) and reoperative wound debridement (OR, 5.1; P=0.07).

In 2022 and 2021, the American Society of Plastic Surgeons (ASPS) issued practice guidelines and a companion document on criteria for third-party payers for reduction mammoplasty, respectively. The ASPS found that level I evidence has shown that reduction mammoplasty 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 indicated the volume or weight of breast tissue resection should not be criteria for reduction mammoplasty. If two or more symptoms are present all or most of the time, reduction mammoplasty is appropriate. 

A 2012 systematic review of studies by Singh and Losken reported on outcomes after reduction mammoplasty and found that reduction mammoplasty improved functional outcomes, including pain, breathing, sleep, and headaches; the authors also reported on psychological outcomes and showed improvements in self-esteem, sexual function, and QOL in addition to less anxiety and depression.

A systematic review by Thibaudeau et al. was conducted in 2010 to evaluate breastfeeding after reduction mammoplasty. The authors reviewed literature from 1950 through 2008 and concluded that reduction mammoplasty does not reduce the ability to breastfeed. The authors reported similar rates of breastfeeding in women who had reduction mammoplasty in the first month postpartum to the general population in North America.

In 2016, Beraldo et al. assessed the sexual function and depression outcomes among individuals with breast hypertrophy undergoing reduction mammoplasty in a randomized trial of 60 individuals. At 6 months, the authors reported higher Female Sexual Function Index scores in the reduction mammoplasty group versus the no-surgery group (27.5 vs 22.5; P<0.001) and lower levels of depression as measured by the Beck Depression Inventory in the reduction mammoplasty group versus the no-surgery group (7.2 vs 13.7; P=0.01).

In 2016, Hernanz et al. reported on a descriptive cohort study of 37 consecutive obese individuals 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 individuals with symptomatic macromastia (40) than for age-matched controls (53; P<0.001), with differences in five of the eight subscales. At 18 months postprocedure, there was no significant difference in any SF-36 subscores except the body pain subscale between individuals who had undergone reduction mammoplasty and age-matched controls.

Overall, reduction mammoplasty in appropriately selected individuals is associated with improvements in several health outcomes. However, the criteria for medically necessary reduction mammoplasty are not well addressed in current professional literature. Therefore, individual selection criteria cannot rely solely on an evidence-based approach. Relevant studies indicate that functional limitations related to breast hypertrophy are improved following reduction mammoplasty. Volume or weight of the potential breast tissue resection should be combined with other concurrent symptoms to determine the appropriateness of reduction mammoplasty for an individual.

Current literature suggests that a baseline mammogram should be performed before the mammoplasty because mammographic findings after this surgery are predictable. Having a baseline reading prevents unnecessary biopsies and assists with diagnosing lesions unrelated to the procedure.

References

American Society of Plastic Surgeons (ASPS). Evidence-based Clinical Practice Guideline ​Revision: Reduction Mammaplasty. ​Plast Reconstruc Surg. 2022;149(3):392e-409e.

American Society of Plastic Surgeons. Reduction Mammaplasty: ASPS Recommended Insurance Coverage Criteria for Third-Party Payers. Updated 2021; Original 2011. Available at: https://www.plasticsurgery.org/documents/Health-Policy/Reimbursement/insurance-2021-reduction-mammaplasty.pdf. Accessed ​March 12, 2025.​

Beraldo FNM, Veiga DF, Veiga-Filho J, et al. Sexual function and depression outcomes among breast hypertrophy patients undergoing reduction mammaplasty: a randomized controlled trial. ​Ann Plast Surg. 2016;76(4):379-382. 

Botta SA. Alternatives for the surgical correction of severe gynecomastia. Aesthetic Plast Surg. 1998;22(1):65-70.

Braunstein GD. Diagnosis and treatment of gynecomastia. Hosp Pract. 1993;28(10A):37-46.

Chadbourne, EB, Zhang S, Gordon MJ, et al. Clinical outcomes in reduction mammoplasty: a systematic review and meta-analysis of published studies. Mayo Clin Proc. 2001:76(5)503-510.

Chen CL, Shore AD, Johns R, et al. The impact of obesity on breast surgery complications. Plast Reconstr Surg. 2011;128(5):395e-402e.

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):1556-1666.

Cordova A, Moshella F. Algorithm for clinical evaluation and surgical treatment of gynaecomastia. J Plastic Aesthet Surg. 2008;61(1):41-49.

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.

Dabbah A, Lehman JA Jr, Parker MG, et al. Reduction mammoplasty: An outcome analysis. Ann Plast Surg. 1995;35(4):337-341.

Danikas D, Theodorou SJ, Kokkalis G, et al. Mammographic findings following reduction mammoplasty. Aesthetic Plast Surg. 2001:25(4):283-285.

Frantz AG. Endocrine disorders of the breast. In: Wilson JD, Foster DW, Kronenberg HM, Larsen PR, eds. Williams Textbook of Endocrinology. 9th ed. Philadelphia, PA: WB Saunders Company; 1998: 886-887.

Geiker NR, Horn J, Astrup A. Preoperative weight loss program targeting women with overweight and hypertrophy of the breast - a pilot study. Clin Obes. 2017;7(2):98-104.

Glass AR. Gynecomastia. Endocrinol Metab Clin North Am. 1994;23(4):825-837.

Glass G, Soldin M. The effect of new inclusion criteria on patient selection for reduction mammoplasty. Department of Plastic and Reconstructive Surgery, London, UK. Clinical Governance: An International Journal. 2007;12(1):6-12.

Glatt BS, Sarwer DB, O'Hara DE, et al. A retrospective study of changes in physical symptoms and body image after reduction mammoplasty. Plast Reconstr Surg. 1999;103(1):76-85.

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.

Hage JJ, Karim RB. Risk of breast cancer among reduction mammoplasty patients and the strategies used by plastic surgeons to detect such cancer. Plast Reconstr Surg. 2006;117(3):727-736.

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. 2016;69(8):e168-e173.

Hidalgo DA, Elliot LF, Palumbo S, et al. Current trends in breast reduction. Plast Reconstr Surg. 1999;104(3):806-815.

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. 2006a;118(1):1-6; discussion 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. 2006b;93(3):291-294.

Kalliainen LK. ASPS Clinical Practice Guideline Summary on Reduction Mammaplasty. Plast Reconstr Surg. 2012;130(4):785-789.

Kauf E. Gynecomastia in childhood. Pathological causes unusual but serious. Fortschur Med. 1998;116(35-36):23-26.

Kerrigan CL, Collins ED, Kim HM, et al. Reduction mammoplasty: Defining medical necessity. Med Decis Making. 2002;22(3):208-217.

Krieger LM, Lesavoy MA. Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammoplasty. Plast Reconstr Surg. 2001;107(5);1234-1240.

Kumar RJ, Barqawi A, Crawford ED. Adverse events associated with hormonal therapy for prostate cancer. Rev Urol. 2005;7 Suppl 5:S37-S43.

Miller BJ, Morris SF, Sigurdson LL, et al. Prospective study of outcomes after reduction mammoplasty. Plast Reconstr Surg. 2005;115(4):1025-1031.

Myung Y, Heo CY. Relationship between obesity and surgical complications after reduction mammaplasty: a systematic literature review and meta-analysis. Aesthet Surg J. 2017;37(3):308-315.

Nelson JA, Fischer JP, Chung CU, et al. Obesity and early complications following reduction mammaplasty: An analysis of 4545 patients from the 2005-2011 NSQIP datasets. J Plast Surg Hand Surg. 2014;48(5):334-339.

Neuman JF. Evaluation and treatment of gynecomastia. Am Fam Physician.1997;55(5):1835-1844, 1849-1850.

Nordt CA, DiVasta AD. Gynecomastia in adolescents. Curr Opin Pediatr. 2008;20(4):375-382.

Novitas Solutions, Inc. Local Coverage Article (LCA). A56587: Billing and Coding: Cosmetic and Reconstructive Surgery. [Novitas Solutions Web site]. Original: 05/30/2019. (Revised: ​01/01/2025). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=56587. Accessed March 12, 2025. 
Novitas Solutions, Inc. Local Coverage Determination (LCD). L35090: Cosmetic and Reconstructive Surgery. [Novitas Solutions Web site]. Original: 10/01/2015. (Revised: 07/11/2021). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=35090&DocID=L35090. Accessed March 12, 2025. 

Nuzzi LC, Firriolo JM, Pike CM, et al. The effect of reduction mammaplasty on quality of life in adolescents with macromastia. Pediatrics. 2017;140(5). pii: e20171103.

Pensler JM, Delgado MA Jr, Yost MJ. Plastic surgery for gynecomastia. [eMedicine Web site]. 06/06/2023. Available at: http://emedicine.medscape.com/article/1273437-overview. Accessed March 12, 2025.​

Perdikis G, Dillingham C, Boukovalas S, et al. American Society of Plastic Surgeons Evidence-Based Clinical Practice Guideline Revision: Reduction Mammaplasty. Plast Reconstr Surg. 2022;149(3):392e-409e.
Sabino Neto M, Dematte MF, Freire M, et al. Self-esteem and functional capacity outcomes following reduction mammaplasty. Aesthetic Surg J. 2008;28(4):417-420.

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):1472-1478.

Schnur PL. Reduction mammoplasty - the Schnur sliding scale revisited. Ann Plast Surg. 1999;42(1);107-108.

Schnur PL, Hoehn JG, llstrup D, et al. Reduction mammoplasty: cosmetic or reconstructive procedure? Ann Plast Surg. 1991;27(3):232-237.

Schnur PL, Schnur DP, Petty PM, et al. Reduction mammoplasty: an outcome study. Plast Reconstr Surg. 1997;100(4):875-883.
Shermak MA, Chang D, Buretta K, et al. Increasing age impairs outcomes in breast reduction surgery. Plast Reconstr Surg. 2011;128(6):1182-1187.

Singh KA, Losken A. Additional benefits of reduction mammaplasty: a systematic review of the literature. Plastic Reconstr Surg. 2012;129(3):562-570.

Thibaudeau S, Sinno H, Williams B. The effects of breast reduction on successful breastfeeding: a systematic review. J Plast Reconstr Aesthet Surg. 2010;63(10):1688-1693.

Torresetti M, Zuccatosta L, Di Benedetto G. The effects of breast reduction on pulmonary functions: A systematic review. J Plast Reconstr Aesthet Surg. 2022;75(12):4335-4346.

Coding

CPT Procedure Code Number(s)
15877, 19318
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
THE FOLLOWING IS USED TO REPORT MEDICALLY NECESSARY CRITERIA USING PRIMARY DIAGNOSIS AND CLINICAL SYMPTOMS

PRIMARY DIAGNOSIS
N62Hypertrophy of breast
​N65.1
​Disproportion of reconstructed breast


CLINICAL SYMPTOMS
L26   Exfoliative dermatitis
L30.4 Erythema intertrigo
L54   Erythema in diseases classified elsewhere
L95.1 Erythema elevatum diutinum
L98.2 Febrile neutrophilic dermatosis [Sweet]
M25.511Pain in right shoulder
M25.512Pain in left shoulder
M54.2 Cervicalgia
M54.6 Pain in thoracic spine
M54.9  Dorsalgia, unspecified
N61.1
Abscess of the breast and nipple
N61.21
Granulomatous mastitis, right breast
N61.22
Granulomatous mastitis, left breast
N61.23
Granulomatous mastitis, bilateral breast
N64.1
Fat necrosis of breast​
N64.81Ptosis of breast
O91.211Nonpurulent mastitis associated with pregnancy, first trimester
O91.212Nonpurulent mastitis associated with pregnancy, second trimester
O91.213Nonpurulent mastitis associated with pregnancy, third trimester
R21   Rash and other nonspecific skin eruption
Z48.3  Aftercare following surgery for neoplasm
HCPCS Level II Code Number(s)
N/A
Revenue Code Number(s)
N/A


Coding and Billing Requirements

Policy History

Revisions From 11.08.02l:
​04/30/2025
​This policy has been reviewed and reissued to communicate the Company’s continuing position on reduction mammoplasty.​
06/03/2024
This version of the policy will become effective 06/03/2024. 

​Policy criteria addressing Reduction Mammoplasty was revised to better clarify the conditions in which Reduction Mammoplasty is Medically Necessary.

The following criteria were added:
  • For adolescents, the cup size is stable (i.e., has not changed) for at least 6 months
  • There is reasonable likelihood that the individual's symptoms are primarily due to the size or weight of the breasts
Furthermore, diagnosis code N65.1 (Disproportion of reconstructed breast) was changed from Clinical Symptom to Primary Diagnosis.

Revisions From 11.08.02k:
09/25/2023
This version of the policy will become effective 09/25/2023. The intent of this policy remains unchanged; however, the following criteria have been added:
  • ​The macromastia/gigantomastia is not caused by an active endocrine, pharmaceutical, or metabolic process. If an active endocrine, pharmaceutical, or metabolic process is found, macromastia/gigantomastia and related symptoms persist after nonsurgical treatment (e.g., discontinuation of a known pharmaceutical agent, when medically appropriate).​

Revisions From 11.08.02j:
12/19/2022
This version of the policy will become effective 12/19/2022. 

The intent of this policy remains unchanged. Language addressing medical necessity of reduction mammoplasty for the treatment of gigantomastia of pregnancy was added.

The following ICD-10 Diagnosis Codes have been added to this policy:
N61.1 Abscess of the breast and nipple
N61.21 Granulomatous mastitis, right breast
N61.22 Granulomatous mastitis, left breast
N61.23 Granulomatous mastitis, bilateral breast
N64.1 Fat necrosis of breast
O91.211 Nonpurulent mastitis associated with pregnancy, first trimester
O91.212 Nonpurulent mastitis associated with pregnancy, second trimester
​O91.213 Nonpurulent mastitis associated with pregnancy, third trimester

Revisions From 11.08.02i:
06/16/2021
This policy has been reissued in accordance with the Company's annual review process.​
​01/01/2021
​This policy has been identified for the CPT code update, effective 01/01/2021.

The following CPT narrative has been revised ​in this policy: 19318​

​Revisions From 11.08.02h:
​06/03/2020
​The policy has been reviewed and reissued to communicate the Company’s continuing position on Reduction Mammoplasty.
06/05/2019This policy has been reissued in accordance with the Company's annual review process.
05/07/2018This version of the policy will become effective 05/07/2018. The intent of this policy remains unchanged. In Guidelines sections, revised parameters to consistently follow rounding convection when discrepancies noted from source.

The following CPT code has been removed from this policy: 15777

Effective 10/05/2017 this policy has been updated to the new policy template format.
6/3/2024
6/3/2024
4/30/2025
11.08.02
Medical Policy Bulletin
Commercial
No
Connect with Us

2026 Independence Blue Cross

Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.