Pending Policies - Surgery


Reduction Mammaplasty

Number:SUR716.012

Effective Date:01-15-2018

Coverage:

*CAREFULLY CHECK STATE REGULATIONS AND/OR THE MEMBER CONTRACT*

Many contracts have exclusions for services or supplies provided for cosmetic procedures. For example, the following services would not be covered for a cosmetic breast reduction (unilateral or bilateral) which is unrelated to post mastectomy reconstruction with contralateral breast surgery, post accidental injury or trauma:

Diagnostic evaluation of, or

Preparation for, or

Conjunction with, or

Treatment of breast hypertrophy or hypermastia.

Therefore, all requests seeking coverage of reduction mammaplasty must include all required documentation before a medical necessity determination can be made.

Reduction mammaplasty for symptomatic breast hypertrophy or hypermastia in patients who are 18 years or older may be considered medically necessary when ALL the following criteria are met:

1. The patient has significant symptoms, documented in their medical records, that interfere with activities of daily living, including but not limited to, the following:

a) Pain in the upper back, neck, and shoulders, which is long-standing in duration and increasing in intensity and is not related to other musculoskeletal causes (e.g., poor posture, acute strains, post traumatic conditions, poor lifting techniques, or other evidence of overuse), OR

b) Persistent, clinical, nonseasonal submammary intertrigo, which is refractory and unresponsive to comprehensive local hygiene and topical anti-infective therapy, OR

c) Ulnar nerve paresthesia or compression, which results in pain and/or numbness in the arms and/or hands; AND

2. The patient’s history and physical exam documents the following:

a) Significant shoulder grooving or ulceration of the skin of the shoulder; AND

b) Obvious breast hypertrophy; AND

c) Physical exam consistent with symptoms precipitating request for reduction mammaplasty; AND

d) Failure of at least 6-weeks of conservative measures including:

Physical therapy for back, neck or shoulder pain including a maintenance home exercise program, or

Appropriate support bra with weight distributing straps, or

Appropriate local hygiene and topical pharmacologic treatments for intertrigo; AND

e) Documentation of patient’s body surface area (BSA), based on the Schnur Sliding Scale (SSS), in which the patient’s breast weight (per breast) is estimated at greater than the 22nd percentile line (Refer to SSS and calculation of BSA in the Rationale Section) consisting of breast tissue, not fatty tissue to be removed.

Photo Documentation Requirements: Photo documentation that is consistent with the physical exam findings of breast hypertrophy and shoulder grooving.

NOTE: Claims are subject to review for the actual amount of breast tissue removed. The final coverage determination may be based on a post-operative pathology report confirming the amount and type of breast tissue resected and that this amount is greater than the 22nd percentile of the SSS nomogram based upon the patient’s pre-operative BSA and that the tissue removed consisted of breast and not adipose or fatty tissue.

Reduction mammaplasty is considered cosmetic and not medically necessary for the treatment of psychosocial indications or as a method to restore normal emotional functioning.

Use of liposuction, with or without ultrasound assistance, to perform a reduction mammaplasty is considered experimental, investigational and/or unproven.

Description:

Macromastia, or gigantomastia, is a condition that describes breast hyperplasia or hypertrophy. Macromastia may result in clinical symptoms such as shoulder, neck pain, back pain, or recurrent intertrigo in the mammary folds. In addition, macromastia may be associated with psychosocial or emotional disturbances related to the large breast size.

Background

Reduction mammaplasty is a surgical procedure designed to remove a variable proportion of breast tissue to address emotional and psychosocial issues and/or to relieve the associated clinical symptoms. The patient is evaluated by comparing their overall body stature with the size of their breasts, to estimate the excess of breast tissue and confirm the diagnosis. Utilization of the Schnur Sliding Scale (SSS) assists in the evaluation of the minimum amount of breast tissue to be removed when compared to the patient’s body surface area. A full discussion of the SSS can be found in the Rationale of this medical policy.

Regulatory Status

Reduction mammaplasty is a surgical procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration.

Rationale:

This policy was originally created in 1991 and has been updated with searches of the MedLine database. The most recent literature review was performed through April 2017. The following is a summary of the key findings to date.

While the literature search identified many articles that discuss the surgical technique of reduction mammaplasty and document that reduction mammaplasty is associated with a relief of physical and psychosocial symptoms, (1-9) an important issue is whether reduction mammaplasty is a functional need or cosmetic in nature. For some patients, the presence of medical indications is clear-cut: a clear documentation of recurrent intertrigo or ulceration secondary to shoulder grooving. For some patients, the documentation differentiating between a cosmetic and a medically necessary procedure will be unclear. Criteria for medically necessary reduction mammaplasty are not well-addressed in the published medical literature.

Breast Weight Estimations/Calculations

Some protocols on the medical necessity of reduction mammaplasty are based on the weight of removed breast tissue. The basis of weight criteria is not related to the outcomes of surgery, but to surgeons retrospectively classifying cases as cosmetic or medically necessary. In 1991, Schnur et al., at the request of third-party payers, developed a sliding scale. (10) This scale was based on survey responses from 92 of 200 solicited plastic surgeons, who reported the height, weight, and amount of breast tissue removed from each a breast from the last 15 to 20 reduction mammaplasties they had performed. Surgeons were also asked if the procedures were performed for cosmetic or medically necessary reasons. The data were then used to create a chart relating the body surface area and the cutoff weight of breast tissue removed that differentiated cosmetic and medically necessary procedures. Based on their estimates, those with a breast tissue removed weight above the 22nd percentile likely had the procedure for medical reasons, while those below the 5th percentile likely had the procedure performed for cosmetic reasons; those falling between the cutpoints had the procedure formed for mixed reasons. (Refer to the SSS below.)

In 1999, Schnur reviewed use of the sliding scale as a coverage criterion and reported that, while many payers had adopted it, many had also misused it. (11) Schnur pointed out that if a payer used weight of resected tissue as a coverage criterion, then if the weight fell below the 5th percentile, the reduction mammaplasty would be considered cosmetic; if above the 22nd percentile, it would be considered medically necessary; and if between these cutpoints, it would be considered on a case-by-case basis. Schnur also questioned the frequent requirement that a woman be within 20% of her ideal body weight. While weight loss might relieve symptoms, durable weight loss is notoriously difficult and might be unrealistic in many cases.

Schnur Sliding Scale (SSS)

Schnur Sliding Scale

Body Surface Area in Meters squared (m2)

Breast Weight in Grams (gm) at the 22nd percentile

1.35

199

1.40

218

1.45

238

1.50

260

1.55

284

1.60

310

1.65

338

1.70

370

1.75

404

1.80

441

1.85

482

1.90

527

1.95

575

2.00

628

2.05

687

2.10

750

2.15

819

2.20

895

2.25

978

2.30

1068

2.35

1167

2.40

1275

2.45

1393

2.50

1522

2.55

1662

Calculation of Body Surface Area (BSA), as shown in the following (using centimeters for height and kilograms for weight):

BSA = the square root of ([height x weight] ÷ 3600).

To convert pounds to kilograms, multiply pounds by 0.4536.

To convert inches to centimeters, multiply inches by 2.54.

Efficacy in Reducing Symptoms

Randomized Controlled Trials (RCT)

In 2008, Sabino Neto et al. assessed functional capacity in which 100 patients, ages 18 to 55 years, were randomized to reduction mammaplasty or to waiting list control. (7) Forty-six patients from each group completed the study. At baseline and 6 months later, patients were assessed for functional capacity using the Roland-Morris Disability Questionnaire (0=best performance, 24=worst performance) and for pain using a visual analog scale (VAS). The reduction mammaplasty group showed improvement in functional status, with an average score of 5.9 preoperatively and 1.2 within 6 months postoperatively (p<0.001 for pre-post comparison within the mammaplasty group) versus an unchanged average score of 6.2 in the control group on the first and second evaluations. Additionally, pain in the lower back decreased on the VAS from an average of 5.7 preoperatively to 1.3 postoperatively (p<0.001 for pre-post comparison within the mammaplasty group) versus VAS average scores in the control group of 6.0 and 5.3 on the first and second evaluations, respectively (p=NS [no significant change]).

Also in 2008, Saariniemi et al. reported on quality of life (QOL) and pain in 82 patients randomized to reduction mammaplasty or a nonoperative group and evaluated at baseline and 6 months later. (9) The authors reported that the mammaplasty group had significant improvements in QOL from baseline to 6 months, as measured by the Physical Component Summary score of the 36-Item Short-Form Health Survey (SF-36; change, +9.7 versus +0.7, p<0.001), the Utility Index score (SF-6D; change, +17.5 versus +0.6), the index score of QOL (SF-15D; change, +8.6 versus +0.06, p<0.001), and SF-36 Mental Component Summary score (change, +7.8 versus -1.0, p<0.002). There were also improvements in breast-related symptoms from baseline to 6 months, as measured by Finnish Breast-Associated Symptoms questionnaire scores (-47.9 versus -3.5, p<0.001), and Finnish Pain Questionnaire scores (-21.5 versus -1.0, p<0.001).

Iwuagwu et al. (2006) reported on 73 patients randomized to receive reduction mammaplasty within 6 weeks or after a 6-month waiting period to assess lung function. (8) All patients had symptoms related to macromastia. Postoperative lung function correlated with the weight of breast tissue removed, but there were no significant improvements in any lung function parameters for the mammaplasty group compared with the control group.

Beraldo et al. (2016) reported on a trial of 60 patients randomized to reduction mammaplasty or to no surgery. (12) Trial outcomes were sexual function and depressive symptoms. At 6 months, Female Sexual Function Index scores were higher in the reduction mammaplasty group (27.5 versus 22.5, p<0.001). Level of depression, as measured by the Beck Depression Inventory, was lower in the reduction mammaplasty group (7.2 versus 13.7, p=0.01). Analyses using categories of sexual function or depression showed similar results.

Observational Studies

Singh and Losken (2012) reported on a systematic review of studies reporting outcomes after reduction mammaplasty. (13) In 7 studies reporting on physical symptoms (n range, 11-92 patients), reviewers found reduction mammaplasty improved functional outcomes including pain, breathing, sleep, and headaches. Additional psychological outcomes noted included improvements in self-esteem, sexual function, and QOL.

In 2016, Hernanz et al. reported on a descriptive cohort study of 37 consecutive obese patients who underwent reduction mammoplasty for symptomatic macromastia, along with 37 age-matched women hospitalized for short-stay surgical procedures. (14) In the preoperative state, SF-36 physical health component subscore was significantly lower for patients with symptomatic macromastia (40) than for age-matched controls (53; p<0.001), with differences in 5 of the 8 subscales. At 18 months postprocedure, there was no significant difference in any SF-36 subscores except the body pain subscale between patients who had undergone reduction mammoplasty and age-matched controls.

In 2002, Kerrigan et al. published the results of the BRAVO (Breast Reduction: Assessment of Value and Outcomes) study, a registry of 179 women undergoing reduction mammaplasty. (15) Women were asked to complete QOL questionnaires and a physical symptom count both before and after surgery. The physical symptom count focused on the number of symptoms present that were specific to breast hypertrophy and included upper back pain, rashes, bra strap grooves, neck pain, shoulder pain, numbness, and arm pain. In addition, the weight and volume of resected tissue were recorded. Results were compared with a control group of patients with breast hypertrophy, defined as size DD bra cup, and normal-sized breasts, who were recruited from the general population. The authors proposed that the presence of 2 physical symptoms might be an appropriate cutoff for determining medical necessity for breast reduction. For example, while 71.6% of the hypertrophic controls reported none or 1 symptom, only 12.4% of those considered surgical candidates reported none or 1 symptom. This observation is difficult to evaluate because the study did not report how surgical candidacy was determined. The authors also reported that none of the traditional criteria for determining medical necessity for breast reduction surgery (height, weight, body mass index [BMI], bra cup size, or weight of resected breast tissue) had a statistically significant relation with outcome improvement. The authors concluded that the determination of medical necessity should be based on patients’ self-reported symptoms rather than more objectively measured criteria (e.g., weight of excised breast tissue).

Section Summary: Efficacy in Reducing Symptoms

Systematic reviews, randomized trials, and observational studies have shown that several measures of function and QOL improve after reduction mammaplasty.

Complications

Thibaudeau et al. (2010) conducted a systematic review to evaluate breastfeeding after reduction mammaplasty. (16) After a review of literature from 1950 through December 2008, reviewers concluded that reduction mammaplasty does not reduce the ability to breastfeed. In women who had reduction mammaplasty, breastfeeding rates were comparable in the first month postpartum to rates in the general population in North America.

In 2011, Chen et al. reported on a review of claims data to compare complication rates after breast surgery in 2403 obese and 5597 nonobese patients. (17) Of these patients, breast reduction was performed in 1939 (80.7%) in the study group and in 3569 (63.8%) in the control group. Obese patients had significantly more claims for complications within 30 days after breast reduction surgery (14.6%) than nonobese patients (1.7%; p<0.001). Complications included inflammation, infection, pain, and seroma/hematoma development. Also in 2011, Shermak et al. reported on a review of claims data comparing complication rates by age after breast reduction surgery in 1192 patients. (18) Infection occurred more frequently in patients older than 50 years of age (odds ratio [OR], 2.7; p=0.003). Additionally, women older than 50 years experienced more wound healing problems (OR=1.6; p=0.09) and reoperative wound débridement (OR=5.1; p=0.07). Other retrospective evaluations (2013, 2014) of large population datasets have reported an increased incidence of perioperative and postoperative complications with high BMI. (19, 20)

Section Summary: Complications

Several randomized trials and observational studies have shown improvements in several measures of function and QOL.

Ongoing and Unpublished Clinical Trials

A search of ClinicalTrials.gov in April 2017 did not identify any ongoing or unpublished trials that would likely influence this review.

Practice Guidelines and Position Statements

American Society of Plastic Surgeons (ASPS)

The ASPS has issued practice guidelines and a companion document on criteria for third-party payers for reduction mammaplasty. (21-23) ASPS found level I evidence has shown reduction mammaplasty is effective in treating symptomatic breast hypertrophy, which “is defined as a syndrome of persistent neck and shoulder pain, painful shoulder grooving from brassiere straps, chronic intertriginous rash of the inframammary fold, and frequent episodes of headache, backache, and neuropathies caused by heavy breasts caused by an increase in the volume and weight of breast tissue beyond normal proportions.” ASPS also indicated the volume or weight of breast tissue resection should not be criteria for reduction mammaplasty. If 2 or more symptoms are present all or most of the time, reduction mammaplasty is appropriate.

Summary of Evidence

For individuals who have symptomatic macromastia who receive reduction mammaplasty, the evidence includes systematic reviews, randomized controlled trials, and case series. Relevant outcomes are symptoms and functional outcomes. These studies have indicated that reduction mammaplasty is effective at decreasing breast-related symptoms such as pain and discomfort. There is also evidence that functional limitations related to breast hypertrophy are improved after reduction mammaplasty. These outcomes are achieved with acceptable complication rates. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

CODING:

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

19318

HCPCS Codes

None

ICD-9 Diagnosis Codes

Refer to the ICD-9-CM manual

ICD-9 Procedure Codes

Refer to the ICD-9-CM manual

ICD-10 Diagnosis Codes

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.

A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.

References:

1. Dabbah A, Lehman JA, Jr., Parker MG, et al. Reduction mammaplasty: an outcome analysis. Ann Plast Surg. Oct 1995; 35(4):337-41. PMID 8585672

2. Schnur PL, Schnur DP, Petty PM, et al. Reduction mammaplasty: an outcome study. Plast Reconstr Surg. Sep 1997; 100(4):875-83. PMID 9290655

3. Hidalgo DA, Elliot LF, Palumbo S, et al. Current trends in breast reduction. Plast Reconstr Surg. Sep 1999; 104(3):806-15; quiz 16; discussion 17-8. PMID 10456536

4. 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. Jan 1999; 103(1):76-82; discussion 83-5. PMID 9915166

5. Collins ED, Kerrigan CL, Kim M, et al. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plast Reconstr Surg. Apr 152002; 109(5):1556-66. PMID 11932597

6. Iwuagwu OC, Walker LG, Stanley PW, et al. Randomized clinical trial examining psychosocial and quality of life benefits of bilateral breast reduction surgery. Br J Surg. Mar 2006; 93(3):291-4. PMID 16363021

7. Sabino Neto M, Dematte MF, Freire M, et al. Self-esteem and functional capacity outcomes following reduction mammaplasty. Aesthet Surg J. Jul-Aug 2008; 28(4):417-20. PMID 19083555

8. Iwuagwu OC, Platt AJ, Stanley PW, et al. Does reduction mammaplasty improve lung function test in women with macromastia? Results of a randomized controlled trial. Plast Reconstr Surg. Jul 2006; 118(1):1-6; discussion 7. PMID 16816661

9. Saariniemi KM, Keranen UH, Salminen-Peltola PK, et al. Reduction mammaplasty is effective treatment according to two quality of life instruments. A prospective randomized clinical trial. J Plast Reconstr Aesthet Surg. Dec 2008; 61(12):1472-8. PMID 17983882

10. Schnur PL, Hoehn JG, Ilstrup DM, et al. Reduction mammaplasty: cosmetic or reconstructive procedure? Ann Plast Surg. Sep 1991; 27(3):232-7. PMID 1952749

11. Schnur PL. Reduction mammaplasty-the Schnur sliding scale revisited. Ann Plast Surg. Jan 1999; 42(1):107-8. PMID 9972729

12. Beraldo FN, Veiga DF, Veiga-Filho J, et al. Sexual function and depression outcomes among breast hypertrophy patients undergoing reduction mammaplasty: a randomized controlled trial. Ann Plast Surg. Apr 2016; 76(4):379-82. PMID 25536204

13. Singh KA, Losken A. Additional benefits of reduction mammaplasty: a systematic review of the literature. Plast Reconstr Surg. Mar 2012; 129(3):562-70. PMID 22090252

14. Hernanz F, Fidalgo M, Munoz P, et al. Impact of reduction mammoplasty on the quality of life of obese patients suffering from symptomatic macromastia: A descriptive cohort study. J Plast Reconstr Aesthet Surg. Aug 2016; 69(8):e168-73. PMID 27344408

15. Kerrigan CL, Collins ED, Kim HM, et al. Reduction mammaplasty: defining medical necessity. Med Dec Making. May-Jun 2002; 22(3):208-17. PMID 12058778

16. Thibaudeau S, Sinno H, Williams B. The effects of breast reduction on successful breastfeeding: a systematic review. J Plast Reconstr Aesthet Surg. Oct 2010; 63(10):1688-93. PMID 19692299

17. Chen CL, Shore AD, Johns R, et al. The impact of obesity on breast surgery complications. Plast Reconstr Surg. Nov 2011; 128(5):395e-402e. PMID 21666541

18. Shermak MA, Chang D, Buretta K, et al. Increasing age impairs outcomes in breast reduction surgery. Plast Reconstr Surg. Dec 2011; 128(6):1182-7. PMID 22094737

19. Nelson JA, Fischer JP, Chung CU, et al. Obesity and early complications following reduction mammaplasty: An analysis of 4545 patients from the 2005-2011 NSQIP datasets. J Plast Surg Hand Surg. Oct 2014; 48(5):334-9. PMID 24506446

20. Gust MJ, Smetona JT, Persing JS, et al. The impact of body mass index on reduction mammaplasty: a multicenter analysis of 2492 patients. Aesthet Surg J Amer Soc Aesthet Plast Surg. Nov 1 2013; 33(8):1140-7. PMID 24214951

21. American Society of Plastic Surgeons. Reduction Mammaplasty: ASPS Recommended Insurance Coverage Criteria for Third-Party Payers: Reduction Mammaplasty. May 2011 (reconfirmed). Available at: <http://www.plasticsurgery.org> (accessed May 22, 2017).

22. Myung Y, Heo CY. Relationship Between Obesity and Surgical Complications After Reduction Mammaplasty: A Systematic Literature Review and Meta-Analysis. Aesthet Surg J. Dec 09 2016. PMID 27940905

23. Kalliainen LK. ASPS Clinical Practice Guideline Summary on Reduction Mammaplasty. Plast Reconstr Surg. Oct 2012; 130(4):785-9. PMID 23018692

24. Reduction Mammaplasty. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (January 2017) Surgery: 7.01.21.

Policy History:

Date Reason
1/15/2018 Document updated with literature review. The following was added to the Coverage section: Photo Documentation Requirements: Photo documentation that is consistent with the physical exam findings of breast hypertrophy and shoulder grooving. The following was changed for failure of conservative measures, which states, “f) Failure of at least 6-weeks of conservative measures including.” The following was removed from failure of conservative measures, “Anti-inflammatory agents unless medically contraindicated.”
8/1/2016 Document updated with literature review. Coverage unchanged.
2/1/2015 Reviewed. No changes.
11/1/2013 Document updated with literature review. Coverage unchanged.
7/15/2009 Coverage revised by adding age limitation of age 18 for consideration if procedure is medically necessary. The word “comprehensive” was removed from coverage criteria.
2/1/2009 The following change(s) were made to Coverage criteria: Application of heat and cold compression as a symptomatic conservative therapy measure removed as a requirement to determine medical necessity.
4/1/2008 Policy reviewed without literature review; new review date only.
1/15/2008 Coverage changed
9/15/2006 Coverage changed
2/15/2006 Revised/updated entire document
9/1/2005 Revised/updated entire document
8/1/1999 Revised/updated entire document
5/1/1996 Medical policy number changed
1/1/1996 Revised/updated entire document
10/1/1994 Revised/updated entire document
6/1/1991 New medical document

Archived Document(s):

Title:Effective Date:End Date:
Reduction Mammaplasty01-01-202205-14-2022
Reduction Mammaplasty07-01-202112-31-2021
Reduction Mammoplasty08-15-202006-30-2021
Reduction Mammaplasty10-15-201908-14-2020
Reduction Mammaplasty01-15-201910-14-2019
Reduction Mammaplasty03-15-201801-14-2019
Reduction Mammaplasty01-15-201803-14-2018
Reduction Mammaplasty08-01-201601-14-2018
Reduction Mammaplasty02-01-201507-31-2016
Reduction Mammaplasty11-01-201301-31-2015
Reduction Mammaplasty07-15-200910-31-2013
Reduction Mammaplasty02-01-200907-14-2009
Reduction Mammaplasty04-01-200801-31-2009
Reduction Mammaplasty01-15-200803-31-2008
Reduction Mammaplasty09-15-200601-14-2008
Reduction Mammaplasty02-15-200609-14-2006
Reduction Mammaplasty09-01-200502-14-2006
Reduction Mammaplasty08-01-199908-31-2005
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