BlueCross and BlueShield of Montana Medical Policy/Codes
Reduction Mammaplasty
Chapter: Surgery: Procedures
Current Effective Date: July 18, 2013
Original Effective Date: June 26, 2001
Publish Date: April 18, 2013
Revised Dates: This policy is no longer scheduled for routine literature review and update. December 15, 2004; October 15, 2011; February 15, 2012; April 17, 2013
Description

Reduction Mammaplasty is a cosmetic reconstruction of the breast to decrease in volume by excision of tissue.  The primary objective of the reduction mammaplasty, commonly known as breast reduction, is to reduce the size of the breast with redraping of the skin envelope.  This provides for the lift and projection of a naturally contoured breast with aesthetically situated nipple-areola complexes and scars.

Macromastia or gigantomastia is an ill-defined term that explains breast hypertrophy or hypermastia.  The diagnosis of female breast hypertrophy is used to describe an increase in the volume and weight of breast tissue in excess of the normal proportion.  Breast hypertrophy may affect one or more of the body systems, such as musculoskeletal, respiratory, and integumentary. The clinical manifestations may include shoulder, neck, or back pain or recurring irritant dermatitis (intertrigo) in the breast folds.  While the response is usually symmetric involvement of both breasts, occasional cases of unilateral hypertrophy occur.  Breast hypertrophy may also become symptomatic after mastectomy on the opposite breast. 

A comparison of overall body stature of the patient with the size of the breast(s) as determined by nipple position, and estimated excess breast tissue weight is evaluated, to confirm the patient's diagnosis. (There can also be a psychological impact for the patient.)  Utilization of the SSS to evaluate the minimum amount of breast tissue to be removed when compared to the patient’s body surface area.

Policy

Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.  Members and their providers have the responsibility for consulting the member's benefit plan 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 or contract, the benefit plan or contract will govern.

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 could be made.

Medically Necessary

BCBSMT may consider Reduction Mammaplasty for symptomatic breast hypertrophy or hypermastia in patients who are 18 years or older allowable for coverage when ALL of the following criteria are met:

  • The patient has significant symptoms, documented in their medical records, that interfere with activities of daily living, including but not limited to, the following –
    1. Pain in the upper back, neck, and shoulders which is long-standing 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 over use), AND/OR
    2. Persistent, clinical, nonseasonal submammary intertrigo, which is refractory and unresponsive to comprehensive local hygiene and topical anti-infective therapy, AND/OR
    3. Ulnar nerve paresthesia or compression, which results in pain and/or numbness in the arms and/or hands.
  • The patient’s physical exam documents the following –
    1. Significant shoulder grooving or ulceration of the skin of the shoulder, AND
    2. Obvious breast hypertrophy, AND
    3. Physical exam consistent with symptoms precipitating request for reduction mammaplasty.
  • Failure of conservative measures including –
    1. A minimum of six (6) weeks of physical therapy for back, neck or shoulder pain including a maintenance home exercise program, AND/OR
    2. Appropriate support bra with weight distributing straps, AND/OR
    3. Anti-inflammatory agents unless medically contraindicated, AND/OR
    4. Appropriate local hygiene and topical pharmacologic treatments for intertrigo.
  • 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 at the end of the Rationale Section) consisting of breast tissue, not fatty tissue to be removed.

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. 

Cosmetic

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

Investigational

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

Policy Guidelines 

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, as shown in the following:

BSA = the square root of [height (centimeters) times weight (kilograms)] divided by 3600.

To convert pounds to kilograms, multiply pounds by 0.4536.

To convert inches to centimeters, multiply inches by 2.54.

Additional avenues of calculation available on BSA are accessible in the:

  • Online Clinical Calculator of the Medical College of Wisconsin web site at http://www.intmed.mcw.edu .
  • Department of Pediatrics, Division of Metabolic Diseases of the University of California, San Diego web site at http://medicine.ucsd.edu .

Rationale

While the literature review identified several articles that discuss the surgical technique of reduction mammaplasty and document that reduction mammaplasty is associated with a relief of physical and psychosocial symptoms, the policy position has always focused on the distinction of whether the proposed reduction mammaplasty is medically necessary or cosmetic in nature.  For some patients, the presence of medical indications is clear-cut, such as clear documentation of recurrent nonseasonal intertrigo or ulceration secondary to shoulder grooving.  However, for the majority of patients, the documentation between a cosmetic and medically necessary procedure will be unclear and subjective in nature.  Criteria for medically necessary reduction mammaplasty are now well addressed in the published medical literature, and thus the optimal patient selection criteria cannot rely on an evidence-based approach. 

The following discussion focuses on the published literature addressing the historical use of weight of excised breast as coverage criteria.  While 500 grams appears to be a commonly sited cut-off weight of excised tissue, there appears to be no documentation in the literature as to the sensitivity and specificity of this value in distinguishing cosmetic from medically necessary procedures.  Also, the use of a single weight cut-off does not address the issue of the relationship between body surface area and weight excised tissue.  In 1991, Schnur and colleagues, at the request of third party payers, developed a sliding scale.  This sliding scale was based on survey responses of 92 out of 200 solicited plastic surgeons, who reported the height, weight, and amount of breast tissue removed from the last 15 to 20 reduction mammaplasties that had been preformed.  The surgeons were also asked if the procedures were preformed 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 the breast tissue removed according to the 5th percentile and the 22nd percentile lines.  Based on their estimates, those with breasts above the 22nd percentile line likely had the procedure performed for medical reasons, while those below the 5th percentile line likely had the procedure performed for cosmetic reason, and those falling between the lines had the procedure done for mixed reasons.

In 1999, Schnur reviewed the experience of the sliding scale as a coverage criterion, and reported that while many payers had adopted this scale, many had also misused it.  The author pointed out that if a payer uses weight of resected tissue as a coverage criterion and if the weight falls below the 5th percentile line, the reduction mammaplasty would be considered cosmetic, above the 22nd percentile line would be considered medically necessary, and those that fell between these lines would be considered on a case by case basis.  The author also questions the frequent requirement that a woman be within 20% of her ideal body weight.  While weight loss might indeed relieve symptoms, durable weight loss is notoriously difficult and may be unrealistic in many cases. (SSS and BSA calculation included at the end of this Rationale discussion.)

In 2002, Kerrigan and Collins published the results of the Breast Reduction: Assessment of Value and Outcomes (BRAVO) study, a registry of 179 women undergoing reduction mammaplasty.  Women were asked to complete quality of life 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 to 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 two physical symptoms might be an appropriate cut-off for determining medical necessity for breast reduction.  For example, while 71.6% of the hypertrophic controls reported none or one symptom, only 12.4% of those were considered surgical candidates who reported none or one symptom.  This observation is difficult to evaluate because the study does 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, bra cup size, or weight of resected breast tissue) had a statistically significant relationship with outcome improvement.  The authors concluded that the determination of medical necessity should be based on patient’s self reports of symptoms rather than more objectively measured criteria, such as weight of excised breast tissue.

Again in 2002, Cruz-Korchin, et al., studied 25 patients who underwent bilateral breast reduction to determine how much of the tissue removed from these patients were fat or other tissue. Each patient’s BMI was calculated Patients were significantly overweight with a mean BMI of 28. Two tissue samples were taken from the central, lateral, and preaxillary areas of the breasts.  In these samples, the percentage of fat, gland, and connective tissue was estimated using low-magnification light microscopy.” They found that the central breast area was an average of 61% fat, 74% in the percentage lateral breast area, and 73% in the preaxillary area. Further examination of the tissues microscopically determined the percent of fat and found that the central breast area was 64% fat, the lateral breast area was 92% fat and the preaxillary area was 94% fat. But the microscopic examination tended to overestimate the amount of fat. On average, the central breast area in macromastia patients had only 7% gland and 29% connective tissue. The lateral and preaxillary areas of the breast had 1-3% gland and 5% connective tissue. The two methods had a significant (p<0.05) positive correlation in the central breast area, but in the lateral and preaxillary regions, the correlation was poor.  They concluded that enlarged breast of macromastia consists primarily of fat and that the glandular element is rather small.  Therefore, the greater the BMI correlates to a higher percentage of fat tissue within the breast, for which a reduction mammaplasty would not be considered medically necessary.

In additional postoperative reduction mammaplasty groups of patients that were surveyed to assess psychological symptoms, the findings of the survey confirmed the therapeutic role of bilateral reduction mammaplasty in the alleviation of symptoms associated with large breasts and in restoration of normal physical and emotional function.

Liposuction (lipoplasty) has evolved to increase the demand for reduced scarring and development of minimal incisional techniques.  Liposuction, with or without ultrasound assistance, provides aesthetic/cosmetic results and are not done for medical necessity.  While there are some published articles concerning the use of liposuction as the sole procedure for breast reduction, none compare the outcomes of liposuction alone to standard excisional reduction mammaplasty.

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. 

ICD-9 Codes
85.31, 85.32, 611.1, 611.8, 719.41, 724.5, v50.1
Procedural Codes: 19318
References
  1. Sabiston, David C., Jr., M.D., ed. 1991. Textbook of Surgery, 14th edition. Philadephia: W.B. Saunders Company:510-50 and 551-5.
  2. Schnur, P.L., Hoehm, J.G., et al. Reduction mammaplasty: cosmetic or reconstructive procedure. Annals of Plastic Surgery (1991 September) 27(3):232-7.
  3. Elsay, N. Recent advances in the treatment of hypertrophy and ptosis of the breast. Journal of the Medical Association of Georgia (1991 November) 80:627-30.
  4. Berkow, Robert M.D., and Andrew J. Fletcher, M.B., B.Chir., eds. 1992. The Merck Manual, 17th edition. New Jersey: Merck & C., Inc.:1812-22.
  5. Female Breast Hypertrophy/Breast Reduction. AMA Practice Parameters (CD Rom/on-line) American Society of Plastic and Reconstructive Surgeons, Inc. (1993 December):1-12.
  6. Reduction Mammaplasty.BCBSA Consortium Health Plan Medical Policy Reference Manual (1995 December 1) Surgery: 7.01.21.
  7. Dabbah, A., Lehman, J.A., et al. Reduction mammaplasty: an outcome analysis. Annals of Plastic Surgery (1995 October) 35(4):337-41.
  8. Davis, G.M., Ringer, S.L., et al. Reduction mammaplasty: long-term efficacy, morbidity, and patient satisfaction. Plastic and Reconstructive Surgery (1995 October) 96(5):1106-10.
  9. Boschert, M.T., Barone, C.M., et al. Outcome analysis of reduction mammaplasty. Plastic and Reconstructive Surgery (1996 September) 98(3):451-4.
  10. Schnur, P.L., Schnur, D.P., et al. Reduction mammaplasty: an outcome study. Plastic and Reconstructive Surgery (1997 September) 100(4):875-83.
  11. NIH.gov and NHLBI.gov – Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NIH Publication No. 98-4083, Full Report and Executive Summary, September 1998.  National Institutes of Health and National Heart, Lung, and Blood Institute. http://www.nhlbisupport.com .
  12. Glatt, B.S., Sarwer, D.B., et al. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Plastic and Reconstructive Surgery (1999 January) 103(1):76-82.
  13. Schnur, P.L. Reduction mammaplasty – the schnur sliding scale revisited. Annals of Plastic Surgery (1999 January) 42(1):107-8.
  14. Hildalgo, D.A., Ellito, L.F., et al. Current trends in breast reduction. Plastic and Reconstructive Surgery (1999 September) 104(3):806-15.
  15. Behmand, R.A. Outcomes in breast reduction surgery. Annals of Plastic Surgery (2000 December 1) 45(6):575-80.
  16. Zubowski, R., Zins, J.E. Relationship of obesity and specimen weight to complications in reduction mammaplasty. Plastic and Reconstructive Surgery (2000 October) 106(5):998-1003.
  17. Chadbourne, E.B., Zhang, S. Clinical outcomes in reduction mammaplasty: A systematic review and meta-analysis of published studies. Mayo Clinic Proceedings (2001 May) 76(5):503-10.
  18. Price, M.F. Liposuction as an adjunct procedure in reduction mammaplasty. Annals of Plastic Surgery (2001 August 21) 47(2):115-8.
  19. Cruz-Korchin, N., Korchin, L, et al. Macromastia: How much of it is fat?  Plastic and Reconstructive Surgery (2002) January 109(1):64-8.
  20. Goes, J.C. Ultrasound – assisted lipoplasty (UAL) in breast surgery. Aesthetic Plastic Surgery (2002 January/February) 26(1):1-9.
  21. Sommer, N.Z, Zook, E.G., et al. The prediction of breast reduction weight. Plastic and Reconstructive Surgery (2002 February 1) 109(2):506-11.
  22. Antoniuk, P.M. Breast augmentation and breast reduction. Obstetrics and Gynecology Clinics (2002 March) 29(1): 1-13.  Web site: http://home.mdconsult.com .
  23. Collins, E.D., Kerrigan, C.L., et al. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plastic and Reconstructive Surgery (2002 April 15) 109(5):1556-66.
  24. Kerrigan, C.L., Collins, E.D, et al. Reduction mammaplasty: Defining medical necessity. Medical Decision Making (2002 May/June) 22(3):208-17.
  25. “Reduction Mammaplasty.” BCBSA Medical Policy Reference Manual (2003 April) Surgery: 7.01.21.
  26. Kompatscher, P., von Planta, A. et al. A body mass index related scale for reconstructive breast reduction. Wiener Medizinsche Wochenschrift (2005 February) 155(3-4):65-9.
History
October 2011 Updated rationale and references, no change in policy statement. Policy not scheduled for further review
February 2012 Policy reviewed with literature search. Policy statement changed to indicate intertrigo must be recurrent or chronic. References 6-9, 13 and 15-18 added.
April 2013 Removed "(breast reduction)" from the title.  Medically necessary criteria revised and more restrictive.  Added the final coverage determination may be based on a post-operative pathology report confirming the amount and type of breast tissue resected.
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Reduction Mammaplasty