Reduction mammoplasty (breast reduction) is a surgical procedure designed to remove a variable proportion of breast tissue. Reduction mammoplasty may be considered medically necessary for the treatment of macromastia causing well-documented clinical symptoms. Procedures performed primarily to improve the appearance of the breast are considered to be cosmetic in nature and therefore not covered. Reduction mammoplasty is considered medically necessary when all of the following criteria are met:

1. The patient has at least a one-year history of significant signs and symptoms that interfere with normal activities, including at least three of the following:
   • Back, neck or shoulder pain not related to other causes such as arthritis, poor posture, acute strains, etc.;
   • Clinical, nonseasonal submammary intertrigo;
   • Significant shoulder grooving or shoulder point tenderness;
   • Breast hypertrophy as evidenced by photographs;
   • Paresthesias of hands/arms;
   • Breast pain.
2. Conservative measures, such as those below, have been tried and have not resulted in significant improvement:
   • For back, neck, or shoulder pain, at least six (6) weeks of conservative treatment including:
     • Appropriate support bra
     • Non-steroid, anti-inflammatory drugs (NSAIDS) (if not contraindicated) 
     • Exercises and heat or cold application
   • For submammary intertrigo, at least six (6) weeks of conservative treatment including:
     • Appropriate hygiene
     • Appropriate medical/pharmacologic treatment
     •  Utilization of an appropriate support bra
3. Patients with a Body Mass Index (BMI) greater than 25, or who are approximately 20% overweight as evidenced by the Metropolitan Life Insurance Company height and weight table (see Attachment A), should have documented and legitimate medically- based attempts to reduce and maintain weight. The weight loss attempts should include all of the following:
   • Regular consultation for at least a three-month period with a practitioner, nutritionist or other weight loss program;
   • Reasonable dietary modifications and appropriate aerobic exercise;
   • Reasonable, good faith attempts by the patient, as documented in the record, to comply with the weight loss program.
4. There must be an estimated minimum of 400 grams of tissue per breast to be removed from women of average height and weight. Cases involving women of significantly smaller stature will be individually considered.
5. Candidates for breast reduction should be at least 18 years of age. Requests for patients under 18 years old will be considered on an individual basis, due to the sensitive nature of performing procedures on the developing breast.

Exceptions:
• For the Federal Employees Program (FEP), the FEP Administrative Manual (FAM) should be reviewed first prior to a determination.

Highmark Medical Policy Bulletin S-28
Anthem Medical Policy #SURG.00023
BlueCross BlueShield of North Carolina #SUR6100
BlueCross BlueShield Association 7.01.21
Companion to CareFirst, INC. Medical Policy 7.01.17
McKesson InterQual Care Planning Criteria HPR-71

In 1943, the Metropolitan Life Insurance Company introduced their standard height-weight tables for men and women. The tables were revised slightly in 1983.

Height & Weight Table For Women