Reduction mammaplasty refers to plastic surgery of the breast to reduce its volume by excision of tissue and (frequently) to improve its shape and position. This policy addresses reduction mammaplasty only and is not intended for application to those undergoing reconstructive procedures after surgery for breast cancer or other clinical indications.  For reconstructive breast procedures, refer to  SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures. For information related to mastectomy for gynecomastia, refer to SURG.00085 Mastectomy for Gynecomastia.

Medically Necessary:

Reduction mammaplasty is considered medically necessary when BOTH of the following criteria (1 and 2) are met:

1. Presence of one or more of the following that has persisted for at least one year:
   
   
   1. A cervical or thoracic pain syndrome (upper back and shoulder pain), in which interference with daily activities or work has been documented. The pain is not associated with other diagnoses (i.e., arthritis, multiple sclerosis, cervical spine disease, etc. have been adequately ruled-out by means of diagnostics, as applicable), and there has been at least three (3) months of adequate conservative treatment with one or more of the following: support garments, NSAIDs, physical therapy, and/or similar modalities; OR
   2. Submammary intertrigo that is refractory to conventional medications and measures used to treat intertrigo, and/or shoulder grooving with ulceration unresponsive to conventional therapy; OR
   3. Thoracic outlet syndrome (to include ulnar paresthesias from breast size) that has not responded to at least three (3) months of adequate conservative treatment.
      
      
2. The preoperative evaluation by the surgeon concludes that an appropriate amount of breast tissue, per breast, will be removed, based upon body surface area or total mass to be removed and that there is a reasonable prognosis of symptomatic relief. The request for surgery must include: the patient’s height and weight; the size and shape of the breast(s) causing symptoms; the anticipated amount of breast tissue to be removed. The Physician Verification Form (Attachment) may be used as an attestation at the discretion of the Health Plan Medical Director. Pictures may be requested to document medical necessity.

Note: The patient’s medical records from the primary care physician may also be requested.

The appropriate amounts (in grams) of breast tissue must be anticipated for removal from each breast, which is based on the patient’s total body surface area (BSA) in meters squared. See Appendix for a table relating BSA values to the minimum amount (weight) of breast tissue to be removed per breast.

To calculate body surface area see:   http://www.medcalc.com/body.html.

Breast reduction surgery is considered medically necessary, regardless of BSA, when the criteria in #1 are met and it is anticipated that at least 1 kg. of breast tissue will be removed from each breast.

Not Medically Necessary:

Breast reduction surgery is considered not medically necessary for patients when the criteria above are not met.

Investigational/Not Medically Necessary:

The use of liposuction to perform breast reduction is considered investigational/not medically necessary.

Cosmetic/Not Medically Necessary:

Breast reduction surgery is considered cosmetic/not medically necessary for the following conditions: poor posture, breast asymmetry, pendulousness, problems with clothes fitting properly and nipple-areola distortion and/or psychological considerations.

In many instances, extremely large breasts have been associated with the development of back, neck and shoulder pain; redness, burning, itching, skin disintegration and cracking; secondary infections; loss of feeling and weakness. Obviously, such symptoms have significant negative impact on the quality of life and may limit physical functioning. In the absence of such symptoms, breast reduction has also been used as a technique to augment the breast for cosmetic purposes.

When the above symptoms exist and cannot be alleviated by conservative methods, such as pain medication, physical therapy, and skin ointments or powders, surgical intervention to reduce the size of the breasts may be indicated. In such cases, scientific studies have shown that a significant amount of breast tissue must be removed, in order to alleviate physical symptoms. Debate has occurred surrounding what should be considered an adequate amount of breast tissue to be removed to achieve adequate symptomatic relief. The medical literature supports an approach, based upon the measurement of body surface area as opposed to a set weight or volume, that does not take a patient's height and body shape into account. The use of the Schnur scale for this measurement is in keeping with accepted medical opinion and the medical evidence, since it is important that an adequate amount of breast tissue be removed, in order to maximize the probability of symptomatic relief. Finally, the use of liposuction, as the primary tool or as an adjunct for reduction mammaplasty, has not been adequately evaluated and has not been demonstrated to improve health outcomes in the medical literature. While there have been many case series reported, a clinical trial comparing the use of liposuction to standard care has not been conducted. In addition, the effectiveness of liposuction, in terms of removing glandular breast tissue, rather than fatty tissue in the breast, remains to be demonstrated. Thus, no clear conclusions can be drawn regarding the efficacy of liposuction, as a surgical technique for reduction mammaplasty.

The evidence supporting the above conclusions concerning the efficacy of reduction mammaplasty includes multiple case series.

Description of Technology

The most common method of breast reduction involves the surgical removal of skin, fat and breast tissue. The procedure is designed to reconstruct the breast with an aesthetically acceptable appearance, while reducing the breast mass. Another proposed method of mammaplasty involves the suction of fatty tissue from the breast (liposuction).

Proposed Benefits

Excess breast mass and weight is believed in some cases to lead to medical problems, such as various pain syndromes and submammary intertrigo (an inflammatory condition affecting the skin directly underneath the breast). Removal of excess breast tissue results in a decrease in breast mass and weight which should theoretically relieve the problems. In order to maximize the potential for symptomatic relief, it is important that an adequate amount of breast tissue be removed.

Possible Risks

Any major surgical treatment can result in significant risks, including the risks of general anesthesia, infection, and bleeding.  However, there are no clear major risks unique to this procedure. In the event the patient develops symptoms of post-operative complications, such as elevated temperature, significant wound inflammation and increased drainage, inability to tolerate oral fluids/diet, increased pain, continued inpatient stay protocols would be implemented, consistent with medical review guidelines.

Intertrigo: a skin condition that occurs in locations where two opposing skin surfaces meet, such as beneath pendulous breasts; redness, burning, itching, infections, and occasionally skin disintegration and cracking characterize this condition.

Reduction mammaplasty: a surgical procedure to decrease breast size.

Thoracic outlet syndrome: a condition resulting from constant pressure on the area between the neck and shoulder where many nerves and blood vessels are located. Symptoms may include pain, weakness, or numbness in the arm on the affected side, (i.e., ulnar paresthesias).

The following codes for treatments and procedures applicable to this policy are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Services may be Medically Necessary when criteria are met:

CPT

ICD-9 Procedure

ICD-9 Diagnosis

When services are Not Medically Necessary or Cosmetic:

For the procedures listed above, when criteria are not met; or when the code describes a procedure indicated in the Policy section as not medically necessaryor cosmetic.

When services are Investigational/Not Medically Necessary:

CPT

ICD-9 Diagnosis

Peer Reviewed Publications:

1. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has long-lasting effect. Ann Plastic Surg. 1998; 41(3):240-5. 
2. Chadbourne EB, Zhang S, Gordon MJ, et al. Clinical outcomes in reduction mammaplasty: a systemic review and meta-analysis of published studies. Mayo Clin Proc. 2001; 76(5):503-10.
3. Chao JD, Memmel HC, Redding JF, et al. Reduction mammaplasty is a functional operation, improving quality of life in symptomatic women: a prospective, single-center breast reduction outcome study. Plast Reconstr Surg. 2002; 110(7):1644-52.
4. 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):1556-66. 
5. Cunningham BL, Gear AJ, Kerrigan CL, Collins ED. Analysis of breast reduction complications derived from the BRAVO study. Plast Reconstr Surg. 2005; 115(6):1597-604. 
6. Dabbah A, Lehman JA Jr, Parker MG, et al. Reduction mammaplasty: an outcome analysis. Ann Plast Surg. 1995; 35(4):337-41.
7. Davis GM, Ringler SL, Short K, et al. Reduction mammaplasty: long-term efficacy, morbidity, and patient satisfaction. Plast Reconstr Surg. 1995; 96(5):1106-10. 
8. Di Giuseppe A. Breast reduction with ultrasound-assisted lipectomy. Plast Reconstr Surg. 2003; 112(1):71-82.
9. Glatt BS, Sarwer DB, O’Hara DE, et al. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Plast Reconstr Surg. 1999; 103(1):76-82. 
10. Gonzalez F, Walton RL, Shafer B, et al. Reduction mammaplasty improves symptoms of macromastia. Plast Reconstr Surg. 1993; 91(7):1270-6.
11. Gray LN. Update on experience with liposuction breast reduction. Plast Reconstr Surg. 2001; 108(4):1006-10.
12. Hooper DM, Ricciardelli EJ, Goel VK, Aleksiev A. Biomechanical changes in the low back following reduction mammaplasty surgery. Clin Biomech (Bristol, Avon). 1997; 12(7-8):525-27.
13. Kaminer MS, Tan MH, Hsu TS. Limited breast reduction by liposuction. Skin Therapy Lett. 2002; 7(10):6-8. 
14. Kerrigan CL, Collins ED, Kim HM, et al. Reduction mammaplasty: defining medical necessity. Med Decis Making. 2002; 22(3):208-17.
15. Kerrigan CL, Collins ED, Kneeland TS, et al. Measuring health state preferences in women with breast hypertrophy. Plast Reconstr Surg. 2000. 106(2):280-8.
16. Kompatscher P, von Planta A, Spicher I, et al. Comparison of the incidence and predicted risk of early surgical site infections after breast reduction. Aesthetic Plast Surg. 2003; 27(4):308-14.
17. Matarasso A. Suction mammaplasty: the use of suction lipectomy to reduce large breasts. Plast Reconstr Surg. 2000; 105(7)2604-7.
18. Matarasso SL. Liposuction of chest and back. Dermatol Clin. 1999; 17(4):799-804. 
19. Miller AP, Zacher, Berggren RB, et al. Breast reduction for symptomatic macromastia: can predictors for operative success be identified? Plast Reconstr Surg. 1995; 95(1):77-83. 
20. Miller BJ, Morris SF, Sigurdson LL, et al. Prospective study of outcomes after reduction mammaplasty. Plast Reconstr Surg. 2005; 115(4):1025-31.
21. Mosteller RD. Simplified calculation of body-surface area. N Engl J Med. 1987; 317(17):1098. 
22. Netscher DT, Meade RA, Goodman CM, et al. Physical and psychosocial symptoms among 88 volunteer subjects compared with patients seeking plastic surgery procedures to the breast. Plast Reconstr Surg. 2000; 105(7):2366-73.
23. Schnur PL, Hoehn JG, Ilstrup DM, et al. Reduction mammaplasty: cosmetic or reconstructive procedure? Ann Plast Surg. 1991; 27(3): 232-7.
24. Schnur PL, Schnur DP, Petty PM, et al. Reduction mammaplasty: an outcomes study. Plast Reconstr Surg. 1997; 100(4):875-83.
25. Schnur PL. Reduction mammaplasty-the schnur sliding scale revisited. Ann Plast Surg. 1999; 42(1):107-8.
26. Seitchik MW. Reduction mammaplasty: criteria for insurance coverage. Plast Reconstr Surg. 1995; 95(6):1029-32. 
27. Sood R, Mount DL, Coleman JJ 3^rd, et al. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. Plast Reconstr Surg. 2003; 111(2):688-94. 
28. Wagner DS, Alfonso DR. The influence of obesity and volume of resection on success in reduction mammaplasty: an outcomes study. Plast Reconstr Surg. 2005; 115(4):1034-8.
    

Government Agency, Medical Society, and Other Authoritative Publications: 

1. American Society of Plastic Surgeons. Reconstruction surgery of the breast: Reduction mammaplasty. Available at: http://www.plasticsurgery.org. Accessed on May 2, 2006. 

1. American Academy of Orthopaedic Surgeons. Thoracic Outlet Syndrome. Available at:  http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=206&topcategory=Shoulder. Accessed on May 2, 2006. 
2. National Institute of Neurological Disorders and Stroke. NINDS thoracic outlet syndrome information page. Available at:  http://www.ninds.nih.gov/health_and_medical/disorders/thoracic_doc.htm. Accessed on May 2, 2006.
   

Mammaplasty

Reduction Mammaplasty

Appendix:

Minimum Weight of Breast Tissue Removed, per Breast, as a Function of Body Surface Area

Schnur Sliding Scale

Attachment

Reduction Mammaplasty
Physician Verification Form

1. The patient has one or more of the following (circle all that apply), which has persisted for at least one year:
   1. Cervical or thoracic pain syndrome which interference with daily activities or work and is not associated with other diagnoses (i.e., arthritis, disc disease, multiple sclerosis, etc)
      OR
   2. Submammary intertrigo which is refractory to conventional medications and measures used to treat intertrigo, and/or shoulder grooving and ulceration unresponsive to conventional therapy
      OR
   3. Thoracic outlet syndrome
2. The patient has not responded adequately to at least three months of adequate conservative treatment with (circle all that apply) support garments, NSAIDs, physical therapy, exercise program, Chiropractic or Osteopathic care.
3. There is a reasonable prognosis of symptom relief.
4. Patient Height:______ Weight:________ Proposed amount of tissue to be removed, each breast:__________
   BSA:_______

(Anticipated breast tissue to be removed from EACH breast must equal or exceed the following amounts based on body surface area).

Calculation: BSA=square root of {(height in inches x weight in pounds) / 3131}
e.g. Height-5.5" (65inches) x Weight - 160lbs = 10,400/3131 = 3.32 = 1.82 BSA

To calculate body surface area see:  http://www.medcalc.com/body.html.

NOTE:

• Pictures (front and lateral views) of the trunk including shoulders, breasts may be requested to document medical necessity.
• Medical records from the PCP documenting the above will be required for adolescents and may be required in other patients.

The Physician Verification Form is not intended as a substitute for, nor does it preclude, the Prior Authorization/Pre-Certification requirements set forth in the member's contract benefit plan. In addition to this form, as evidenced above, the health plan may, in its sole discretion, request the complete medical record, or any part thereof during the evaluation for determination of medically necessity.

I do attest that the above is true and accurate to the best of my knowledge

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by an means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

©CPT Only - American Medical Association