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:
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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:
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Back, neck or shoulder pain not related to other causes such as arthritis, poor posture, acute strains, etc.;
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Clinical, nonseasonal submammary intertrigo;
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Significant shoulder grooving or shoulder point tenderness;
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Breast hypertrophy as evidenced by photographs;
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Paresthesias of hands/arms;
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Breast pain.
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Conservative measures, such as those below, have been tried and have not resulted in significant improvement:
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For back, neck, or shoulder pain, at least six (6) weeks of conservative treatment including:
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Appropriate support bra
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Non-steroid, anti-inflammatory drugs (NSAIDS) (if not contraindicated)
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Exercises and heat or cold application
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For submammary intertrigo, at least six (6) weeks of conservative treatment including:
- 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.
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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.
Note: For women of small stature, the following sliding scale may be used to determine the required grams removed.
Height
|
Grams
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5'5"
|
700
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5'4"
|
650
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5'3"
|
600
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5'2"
|
550
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5'1"
|
500
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5'0"
|
465
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4'11"
|
435
|
4'10"
|
400
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All questionable cases or cases involving women of very small stature are entitled to individual consideration.
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