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:
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.