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 document addresses reduction mammaplasty only and is not intended for application to those undergoing reconstructive procedures after surgery for breast cancer or other clinical indications.  

Note: For information related to mastectomy for gynecomastia and other reconstructive breast procedures, refer to:

• SURG.00085 Mastectomy for Gynecomastia
• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Medically Necessary: 

Reduction mammaplasty is considered medically necessary when either of the following criteria (I or II) are met:  

1. Individuals meeting BOTH of the following criteria (A and B):
   
   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: special support garments (e.g., special support bras, bras with wide straps), NSAIDs, physical therapy, or similar modalities; or
      2. Submammary intertrigo that is refractory to conventional medications and measures used to treat intertrigo, 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 individual'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: Medical records from the primary care physician and other providers (e.g. physiatrist, orthopedic surgeon, etc.) who have diagnosed or treated the symptoms prompting this request may also be required.

The appropriate amounts (in grams) of breast tissue must be anticipated for removal from each breast, which is based on the individual'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. 

OR

II.  Individuals, regardless of BSA, who are anticipated to have at least 1 kg. of breast tissue removed from each  breast  and who meet the following criteria:

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: special support garments (e.g., special support bras, bras with wide straps), NSAIDs, physical therapy, or similar modalities; or
2. Submammary intertrigo that is refractory to conventional medications and measures used to treat intertrigo, 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.

Not Medically Necessary: 

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

Investigational and Not Medically Necessary: 

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

Cosmetic and Not Medically Necessary:

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

In many instances, extremely large breasts (e.g. macromastia or breast hypertrophy) 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 enhance the appearance of 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 (i.e., the Schnur scale). 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.

Schnur and colleagues (1991) reported the results of two surveys sent to 220 randomly selected board certified plastic surgeons who performed reduction mammaplasties. Ninety-two plastic surgeons returned survey data on 600 women on whom reduction mammaplasty had been performed. Data obtained from the first survey included the height and weight of the individual, as well as the amount of breast tissue removed from each breast. The second survey resulted in an estimate of percentages of women who sought a reduction mammaplasty for purely cosmetic reasons, for purely medical reasons, and for mixed reasons. Based on the results obtained, the authors concluded that if the removed breast tissue weight was greater than the 22^nd percentile, her motivation for the surgery was medical and if the removed breast tissue weight was less than the 5^th percentile, the procedure was sought for cosmetic reasons. Those women whose removed breast tissue weight was between the 5^th and the 22^nd percentile reportedly had mixed reasons for requesting the procedure. In a subsequent outcome study, based on questionnaire responses from women who had undergone reduction mammaplasty, Schnur (1997), reported that in properly selected individuals, reduction mammaplasty is a safe and effective procedure for relieving or improving symptoms related to symptomatic macromastia.

The American Society of Plastic Surgeons (ASPS) (2002a) has indicated that the decision to perform reduction mammaplasty should be based on an individual's symptoms and a surgeon's assessment of the likelihood of benefit as opposed to the amount (weight) of breast tissue to be removed. Their position is largely based on observational studies, which are un-blinded, lack randomized control groups and have potential for selection bias, and expert opinion. There have been no further updates to this ASPS position since 2002.

Chadbourne and colleagues (2001) conducted a systematic review and meta-analysis on 29 studies and 4173 individuals. A review of the literature was performed from 1985 until March 1999. Eligible studies were experimental and observational. The studies involved females with preoperative physical or psychosocial signs and symptoms who underwent reduction mammaplasty for breast hypertrophy. Outcomes assessed included postoperative signs and symptoms, such as shoulder pain, shoulder (bra strap) grooving, and quality of life domains. Statistically significant improvement of signs and symptoms was seen between preoperative and postoperative periods. Limitations of the review include recall bias, a high proportion of individuals (25%) without follow-up results, and arbitrary outcome formats (Chadbourne, 2001). Key limitations of this publication are the inherent limitations of "meta-analysis" for evaluating studies which are not randomized controlled trials and that this study was not designed to determine a threshold for weight of tissue to be removed to produce symptom relief.

Collins and colleagues (2002) conducted a prospective controlled study designed to evaluate the efficacy of breast reduction in alleviating symptoms of macromastia by comparing baseline and postoperative health status. Standard outcome instruments were utilized in the study and consisted of the SF-36, EuroQol, Multidimensional Body-Self Relations Questionnaire (MBSRQ), and the McGill Pain Questionnaire (MPQ). The study involved 179 subjects with matched preoperative and postoperative data sets, 96 controls and 88 hypertrophy controls. The women were mainly Caucasian, middle-aged, well educated, and employed. Data from completed questionnaires were gathered preoperatively and then approximately 6 to 9 months post surgery. Outcomes demonstrated that subjects preoperatively had lower scores (p<0.05) in all health domains of the SF-36 and in the mental and physical component summary scores. After surgery, the same group of subjects measured higher than national norms in 7 of the 8 health domains. Preoperative pain scores measured with a Pain Rating Index (PRI) score from the MPQ were reported to be 26.6 and after surgery, pain was stated to be lower with a score of 11.7. Study limitations include non randomization and the possibility that women in this study may have overstated their symptoms or lack of effectiveness of nonsurgical treatments (Collins 2002). Also, the study was not designed to determine a threshold for weight of tissue to be removed to produce symptom relief and there was no comparison of resection weight and extent of symptom relief.

Cunningham and colleagues (2005) analyzed complication data from the Breast Reduction Assessment: Value and Outcomes (BRAVO) Study by Collins (2002). Study data from 179 subjects post breast reduction surgery were analyzed and results demonstrated an overall complication rate of 43 percent (77 individuals). The most common complication was delayed wound healing. Other complications included splitting sutures, hematoma, nipple necrosis, hypertrophic scars, fat necrosis, seroma, and infection. The authors noted that average preoperative breast volume, a vertical incision, and preoperative shoulder grooving were associated with an increased incidence of complications while age, smoking status, body mass index, weight of breast tissue resected, pedicle type, keyhole incision, free nipple grafting, operative time, use of epinephrine, drains, and liposuction were not associated with an increased incidence of complications. The major weaknesses of the study include the small sample size, possible inconsistencies in defining and reporting complications, and the introduction of a new technique (vertical scar) during the study period (Cunningham 2005).

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 case series reported (Habbema, 2009; Sadove, 2005), a clinical trial comparing the use of liposuction to standard surgical reduction mammaplasty 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.

In conclusion, there is a lack of prospective randomized clinical trials with appropriate controls assessing the efficacy of reduction mammaplasty on relief of symptoms. Evidence supporting the efficacy of this surgery includes multiple case series. Since the symptoms are thought to be the result of breast size, based upon the available peer reviewed literature, an individual's signs and symptoms and the amount of breast tissue to be removed should be evaluated before reduction mammaplasty is performed.

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 individual develops symptoms of post-operative complications, such as elevated temperature, significant wound inflammation and increased drainage, inability to tolerate oral fluids or 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.

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 document 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.

When services may be Medically Necessary when criteria are met: 

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met; or when the code describes a procedure indicated in the Position Statement section as not medically necessary.

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above, for the indications listed in the Position Statement section as cosmetic and not medically necessary.

When services are Investigational and Not Medically Necessary: 

Future ICD-10 coding (effective 10/01/2013)
A draft of ICD-10 Coding related to this document, as it might look today, is available for reference and comments at: Appendix 1: Future ICD-10 coding

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):240-245.
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):503-510.
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):1644-1652.
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):1556-1566.
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):1597-1604.
6. Dabbah A, Lehman JA Jr, Parker MG, et al. Reduction mammaplasty: an outcome analysis. Ann Plast Surg. 1995; 35(4):337-341.
7. Davis GM, Ringler SL, Short K, et al. Reduction mammaplasty: long-term efficacy, morbidity, and patient satisfaction. Plast Reconstr Surg. 1995; 96(5):1106-1110.
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):1270-1276.
11. Gray LN. Update on experience with liposuction breast reduction. Plast Reconstr Surg. 2001; 108(4):1006-1010.
12. Habbema L. Breast reduction using liposuction with tumescent local anesthesia and powered cannulas. Dermatol Surg. 2009; 35(1):41-50; discussion 50-52.
13. 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):525-527.
14. Kaminer MS, Tan MH, Hsu TS. Limited breast reduction by liposuction. Skin Therapy Lett. 2002; 7(10):6-8.
15. Kerrigan CL, Collins ED, Kim HM, et al. Reduction mammaplasty: defining medical necessity. Med Decis Making. 2002; 22(3):208-217.
16. Kerrigan CL, Collins ED, Kneeland TS, et al. Measuring health state preferences in women with breast hypertrophy. Plast Reconstr Surg. 2000. 106(2):280-288.
17. 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):308-314.
18. Matarasso A. Suction mammaplasty: the use of suction lipectomy to reduce large breasts. Plast Reconstr Surg. 2000; 105(7):2604-2607.
19. Matarasso SL. Liposuction of chest and back. Dermatol Clin. 1999; 17(4):799-804.
20. 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.
21. Miller BJ, Morris SF, Sigurdson LL, et al. Prospective study of outcomes after reduction mammaplasty. Plast Reconstr Surg. 2005; 115(4):1025-1031.
22. Mosteller RD. Simplified calculation of body-surface area. N Engl J Med. 1987; 317(17):1098.
23. 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):2366-2373.
24. Sadove R. New observations in liposuction-only breast reduction. Aesthetic Plast Surg. 2005; 29(1):28-31.
25. Schnur PL, Hoehn JG, Ilstrup DM, et al. Reduction mammaplasty: cosmetic or reconstructive procedure? Ann Plast Surg. 1991; 27(3): 232-237.
26. Schnur PL, Schnur DP, Petty PM, et al. Reduction mammaplasty: an outcomes study. Plast Reconstr Surg. 1997; 100(4):875-883.
27. Seitchik MW. Reduction mammaplasty: criteria for insurance coverage. Plast Reconstr Surg. 1995; 95(6):1029-1032.
28. 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):688-694.
29. 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):1034-1038.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Society of Plastic Surgeons. Reduction mammaplasty Recommended Criteria for Third–Party Payer Coverage from the American Society of Plastic Surgeons (ASPS). March 9, 2002a. Available at: http://www.plasticsurgery.org/Medical_Professionals/Health_Policy_and_Advocacy/Health_Policy_Resources/
   Recommended_Insurance_Coverage_Criteria.html. Accessed on December 30, 2010.
2. American Society of Plastic Surgeons. Reduction Mammaplasty Practice Parameters. March 9, 2002b. Available at: http://www.plasticsurgery.org/Medical_Professionals/Health_Policy_and_Advocacy/Health_Policy_Resources/Evidence-based_GuidelinesPractice_Parameters.html. Accessed on December 30, 2010.

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 December 30, 2010.
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 December 30, 2010.

Mammaplasty
Mammoplasty
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

Member:________________________ Member ID:___________________________

1. The individual 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 interferes 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 individual 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. Individual's 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 or be equal to or greater than 1 kg. of breast tissue to be removed from EACH breast).

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 primary care physician and other providers (e.g. physiatrist, orthopedic surgeon, etc.) who have diagnosed or treated the symptoms prompting this request may also be required.

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

Physician Name (Print)______________________ Physician Signature:____________________ Date:________