Mountain State Medical Policy Bulletin

Section: Surgery
Number: B-33
Topic: Female Breast Reduction Surgery
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 07/2005

General Policy Guidelines

Indications and Limitations of Coverage

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.

Procedure Codes

19318     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

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

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

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

View Previous Versions

No Previous Versions

Table Attachment

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

Height
Feet Inches

Small
Frame

Medium
Frame

Large
Frame

4' 10"

102-111

109-121

118-131

4' 11"

103-113

111-123

120-134

5' 0"

104-115

113-126

122-137

5' 1"

106-118

115-129

125-140

5' 2"

108-121

118-132

128-143

5' 3"

111-124

121-135

131-147

5' 4"

114-127

124-138

134-151

5' 5"

117-130

127-141

137-155

5' 6"

120-133

130-144

140-159

5' 7"

123-136

133-147

143-163

5' 8"

126-139

136-150

146-167

5' 9"

129-142

139-153

149-170

5' 10"

132-145

142-156

152-173

5' 11"

135-148

145-159

155-176

6' 0"

138-151

148-162

158-179

Weights at ages 25-59 based on lowest mortality. Weight in pounds according to frame (in indoor clothing weighing 3 lbs.; shoes with 1" heels)

Text Attachment

Procedure Code Attachment


Glossary





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.