Mountain State Medical Policy Bulletin |
Section: | Surgery |
Number: | B-33 |
Topic: | Female Breast Reduction Surgery |
Effective Date: | September 10, 2007 |
Issued Date: | September 10, 2007 |
Date Last Reviewed: | 08/2007 |
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:
Note: For women of small stature, the following sliding scale may be used to determine the required grams removed.
All questionable cases or cases involving women of very small stature are entitled to individual consideration. |
19318 |
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 |
[Version 003 of B-33] |
[Version 002 of B-33] |
[Version 001 of B-33] |
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
|