Breast Reduction Surgery - Medical Necessity Criteria
Criteria for documenting medical necessity of breast reduction surgery (reduction mammoplasty/mammaplasty).
Contents:
- When is breast reduction surgery medically necessary?
- Medical necessity criteria for breast reduction surgery
- Frequently Asked Questions
- Are breast reduction surgeries covered by insurance?
- Can breast reduction be covered by Medicare?
- Which insurance covers breast reduction?
- Can breast reduction affect breastfeeding?
- How long is the recovery period after breast reduction surgery?
- Will breast reduction reduce back fat?
- Will breast reduction help shoulder pain?
- Documentation to Submit
- Health plan criteria for breast reduction surgery and other references
Breast reduction surgery — known medically as reduction mammaplasty or reduction mammoplasty — refers to the removal of a portion of the breast by surgery. Both the skin and the underlying tissue are removed. Enough breast tissue is removed until the breast size is within normal range. Breast hypertrophy (over-enlargement) usually affects both breasts so breast reduction surgery is usually performed on both breasts. The surgery is done to help improve symptoms caused by over-large breasts such as back or shoulder pain.
When is breast reduction surgery medically necessary?
Generally, breast reduction surgery may be considered medically necessary in persons whose excessive breast size is causing symptoms that have not improved with conservative treatment. Depending on their health plan, the affected individual will have to meet certain medical necessity criteria for their surgery to be covered.
Excessive breast size is called macromastia or gigantomastia. Breast reduction surgery is called reduction mammoplasty, although it is sometimes also referred to as reduction mammaplasty.
Medical necessity criteria for breast reduction surgery
The patient must be age 18 or older. Some health plans accept those age 16 or older, as long as they have reached breast maturity, as evidenced by a stable cup size for over 6 months.
The patient must have had at least two of the following symptoms for at least one year. (Some health plans require only 6 months.) These symptoms must be directly attributable to macromastia and must adversely affect the patient’s activities of daily living.
- Headaches
- Neck pain
- Shoulder pain
- Upper back pain
- Pain, discomfort, or ulceration caused by bra straps cutting into the shoulders
- Submammary intertrigo — skin symptoms of infection, ulceration, necrosis, or hemorrhage due to overlying breast tissue
- Painful kyphosis — abnormal rounding of the upper back — documented by X-rays
- Paresthesias — such as tingling, numbness, burning, pricking, or chilling — in the upper extremities
Conservative (nonsurgical) treatments must have been tried without success for at least three months. (Some health plans require only 6 weeks.) The treatments that need to have been attempted — as appropriate to patient’s symptoms — include:
- Appropriate support bra / wide bra straps
- Nonsteroidal anti-inflammatory agents/muscle relaxants
- Exercises / physical therapy / chiropractic care
- Heat/cold treatment
- Appropriate medical/pharmacologic treatment (such as antibiotics) of intertrigo
- Orthopedic or spine surgeon evaluation of spinal pain
- Good hygiene
Some health plans require that patients with a body mass index (BMI) greater than 27 must have made a documented attempt to reduce and maintain weight, since obesity is a known risk factor for low back pain and intertrigo.
The estimated amount of breast tissue to be removed must:
- be at least 1 kg from each breast (some health plans only require 500 grams per breast) ; OR
- meet the minimum weight requirement based on the patient’s body surface area (BSA). (Different health plans have different minimum weights, so verify the scale used by the patient’s health plan.)
Breast reduction surgery is considered NOT medically necessary if it is being performed solely: (1) for cosmetic, social, or psychological reasons; (2) to fit into clothing better; or (3) to be able to exercise.
The use of liposuction to achieve breast reduction is generally NOT considered medically necessary.
Frequently Asked Questions
Are breast reduction surgeries covered by insurance?
Breast reduction surgery is covered by insurance when it is considered medically necessary for the patient, that is, if the patient’s condition meets the medical necessity criteria set by their insurance.
Can breast reduction be covered by Medicare?
Local Medicare contractors may cover breast reduction surgery when it is medically necessary.
Which insurance covers breast reduction?
Health insurance companies such as Aetna, Anthem Blue Cross, Health Net, and UnitedHealthcare may cover breast reduction surgery when it is medically necessary.
Can breast reduction affect breastfeeding?
Breast reduction involves removal of at least some glandular tissue. If the breast’s milk ducts and nerves are also cut during surgery, the areola is removed, or the nipple is moved, then there is definitely a high possibility that breastfeeding will be affected.
However, the longer the interval between breast reduction and pregnancy, the better the chance that the patient will still be able to breastfeed. Breast ducts can reconnect to each other, nerves can regenerate, and the best surgeons develop techniques that can preserve breastfeeding-related structures.
How long is the recovery period after breast reduction surgery?
It depends on a lot of factors, and recovery time will not be the same for all women, but patients will generally start to recover a week after surgery, with full recovery taking between 2 to 6 weeks.
Will breast reduction reduce back fat?
Although breast reduction surgery often relieves back pain, it does not directly affect back fat itself.
Will breast reduction help shoulder pain?
Yes. Depending on how much breast tissue is removed, shoulder pain — along with back pain and neck spasms — will tend to improve or sometimes even totally disappear after breast reduction surgery.
Documentation to Submit
These are the things you can prepare documentation of in order to support your statement that breast reduction surgery is medically necessary:
Documentation that breast growth is complete
Photographic documentation of severe breast hypertrophy
Documentation that patient has had symptoms caused by breast hypertrophy for at least 1 year (or 6 months, for some health plans)
Documentation that the following conservative treatments were tried for at least 3 months (or 6 weeks, for some health plans) but were not able to significantly relieve patient’s symptoms:
Health plan criteria for breast reduction surgery and other references
- Aetna Criteria for Breast Reduction Surgery and Gynecomastia Surgery
- Anthem Blue Cross Criteria for Reduction Mammaplasty
- Health Net / Centene Corporation Criteria for Reduction Mammoplasty and Gynecomastia Surgery
- Medicare Local Coverage Determination (LCD) on Reduction Mammaplasty
- UnitedHealthcare Criteria for Breast Reduction Surgery