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Date Printed: June 23, 2017: 11:44 AM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-12000-11

Original Effective Date: 04/17/00

Reviewed: 09/24/15

Revised: 10/15/15

Subject: Reduction Mammoplasty

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Reduction mammoplasty is the surgical procedure, which reduces the size of the breast, by the removal of wedges of skin and breast tissue.

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request to expedite the medical review process.

1. Click the link Reduction Mammoplasty - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

Reduction mammoplasty/mammaplasty for symptomatic breast hypertrophy (macromastia) meets the definition of medical necessity when ALL of the following criteria are met:

– Back pain

– Neck pain

– Shoulder pain

Paresthesias of hands or arms

– Headache

Intertrigo

– Shoulder grooving from brassiere (bra) straps

AND

Note: If breast tissue removed was less than planned, the physician may be asked to provide a letter of explanation to be reviewed by Medical Director for medical necessity.

Reduction mammoplasty/mammaplasty performed to achieve symmetry on a non-disease and contralateral breast following a mastectomy meets the definition of medical necessity.

Liposuction (lipectomy) as an adjunct for breast reduction is included in the primary surgical procedure (reduction mammoplasty/mammaplasty).

For required documentation, refer to the REIMBURSEMENT INFORMATION section of this guideline.

Reduction mammoplasty/mammaplasty does not meet the definition of medical necessity when the above criteria are not met, when performed for cosmetic purposes or for the correction of deformities resulting from previous cosmetic surgery.

Liposuction as the sole procedure for reduction mammaplasty or breast reduction is considered experimental or investigational as there is insufficient clinical evidence to support the use of liposuction as the sole procedure for reduction mammaplasty or breast reduction. There is limited published clinical data evaluating the effectiveness and long-term results of liposuction as a sole procedure for breast reduction to the standard surgical approach.

Refer to section entitled DECISION TREE.

BILLING/CODING INFORMATION:

CPT Coding:

19318

Reduction mammaplasty

REIMBURSEMENT INFORMATION:

Required Documentation

The primary treating physician MUST submit the following information for the member:

• Symptoms and duration

• Height and weight

• Statement of anticipated amount of breast tissue to be removed per breast based upon body surface area in meters squared

• Documentation of conservative therapy and response (e.g., support bra, wide bra straps, analgesia, non-steroidal anti-inflammatory drugs (NSAID), physical therapy, exercises, heat treatment, cold treatment).

LOINC Codes:

Documentation Table

LOINC Codes

LOINC Time Frame Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician visit notes

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician Initial Assessment

18736-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physical therapy progress note

11508-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physical therapy initial assessment

18735-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Perioperative records

29752-3

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Current, discharge, or administered medications

34483-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

NOTE: Photographs are not required with the initial review. Photographs should be maintained as part of the medical record. BCBSF may request photos as part of the review process.

Calculation of Body Surface Area (BSA) (Mosteller Formula)*.

To calculate body surface area (BSA), use the following calculation:

BSA= the square root of height in centimeters (cm) x weight in kilograms (kg) divided by 3600

BSA (m²) = (Height (cm) x Weight (kg) / 3600)½

BSA= the square root of height in inches (in) x weight in pounds (lb) divided by 3131

BSA (m²) = (Height (in) x Weight (lbs) / 3131)½

To convert inches (in) to centimeters (cm), multiply inches (in) by 2.54

To convert pounds (lb) to kilograms (kg), multiply pounds (lb) by 0.45

*Note: See http://www.medcalc.com/body.html for an online version of this formula (Mosteller Formula). This on-line BSA calculator is based on calculations with the given height and weight performed using the calculator on MedCalc.com. The link for this on-line BSA calculator is to an outside source and is provided for your convenience only; the actual BSA calculation formula will prevail over the calculator output on MedCalc.com. Use of the link and related calculator is subject to the terms and conditions of MedCalc.com and is not warranted, maintained or affiliated with Florida Blue. BSA calculations must be confirmed before use.

Schnur Sliding Scale

The Schnur Sliding Scale Table is used to determine breast tissue removal per gram relative to a woman’s body surface area.

Minimum amount of breast tissue
removed per breast in grams:

Body Surface Area
(in meters squared--m2)

22% Percentile Breast Tissue in Grams

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

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products: The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Reduction Mammaplasty, (L29267) located at fcso.com.

DEFINITIONS:

Contralateral: pertaining to or affecting the opposite side.

Hypertrophy: enlargement or overgrowth of an organ or part due to an increase in size of its cells.

Intertrigo: superficial dermatitis occurring on adjacent skin surfaces (e.g., breast fold).

Paresthesia: an abnormal sensation (e.g., burning, pricking, tingling).

Schnur Sliding Scale: a method used to determine breast tissue removal per gram relative to a woman’s body surface area.

RELATED GUIDELINES:

Prophylactic Mastectomy, 02-12000-15

OTHER:

Other terms used to report mammoplasty:

Breast reduction surgery

Reduction Mammaplasty

REFERENCES:

  1. American Society of Plastic and Reconstructive Surgery (ASPS) Cosmetic Plastic Surgery Procedures at a Glance-Liopsuction (Suction-Assisted Lipectomy), 2006.
  2. American Society of Plastic Surgeons, Reduction Mammaplasty – Recommended Insurance Coverage Criteria for Third-Party Payers, 05/11.
  3. Blue Cross Blue Shield Association Medical Policy-Reduction Mammoplasty for Breast-Related Symptoms, 7.01.21, 11/14.
  4. Commons GW, Halperin B, Chang CC. Large-Volume Liposuction: A Review of 631 Consecutive Cases Over 12 Years. Plastic Reconstructive Surgery 2001 Nov; 108(6): 1753-1763; discussion 1764-1767.
  5. First Coast Service Options, Inc. LCD for Reduction Mammaplasty (L29267), 02/02/09.
  6. Krieger LM, Lesavoy MA. Managed care’s methods for determining coverage of plastic surgery procedures: the example of reduction mammaplasty. Plastic and Reconstructive Surgery 2001; 107(5): 1234-1240.
  7. Matarasso A. Suction mammaplasty: the use of suction lipectomy alone to reduce large breast. Clinics in Plastic Surgery 2002; 29(3): 433-443.
  8. Mellul SD, Dryden RM, Remigio DJ et al. Breast Reduction Performed by Liposuction. Dermatology Surgery 2006 Sept; 32(9): 1124-1133.
  9. Moskovitz MJ, Baxt SA, Jain AK et al. Liposuction breast reduction: a prospective trial in African American women. Plastic and Reconstructive Surgery 2007; 119(2): 718-726; discussion 727-728.
  10. Moskovitz MJ, Muskin E, Baxt SA. Outcome study in liposuction breast reduction. Plastic and Reconstructive Surgery 2004; 114(1): 55-60; discussion 61.
  11. Nicoletti G, Scevola S, Faga A. Is breast reduction a functional or a cosmetic operation? Proposal of an objective discriminating criterion. Journal of Plastic, Reconstructive & Aesthetic Surgery: JPRAS 2009, 62(12): 1644-1646.
  12. Piza-Katzer H. Reduction mammaplasty in teenagers. Aesthetic Plastic Surgery 2005; 29(5): 385-390.
  13. Schnur PL. Reduction mammaplsty-the schur sliding scale revisited. Annals of Plastic Surgery 1999; 42(1): 107-108.
  14. Schnur, PL, Hoehn JG, Ilstrup DM et al. Reduction mammaplasty: cosmetic or reconstructive procedure? Annals of Plastic Surgery 1991; 27(3): 232-237.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 09/24/15.

GUIDELINE UPDATE INFORMATION:

04/17/00

Medical Coverage Guideline developed.

03/15/02

MCG reviewed – references updated.

01/15/04

Added program exception for Medicare & More; covered diagnoses. Added diagnosis code 737.0 and V10.3 to billing and coding information section.

06/15/04

Scheduled review. Added reference for InterQual Criteria (2003) for female and male. Added cross-reference for prophylactic mastectomy. Updated references.

06/15/05

Scheduled review. No change in coverage statement. Revised program exceptions. Updated references and related internet links.

10/15/05

Added statement at the end of the WHEN SERVICES ARE COVERED section, referencing the REIMBURSEMENT INFORMATION section for required documentation. Deleted ICD-9 diagnoses codes and added a statement referencing the WHEN SERVICES ARE COVERED and REIMBURSEMENT INFORMATION sections.

05/15/06

Deleted the requirement for submission of photographs from the reimbursement information section. Update references.

07/15/06

Added note regarding maintaining photos as part of the medical record.

01/01/07

Added coverage statement for liposuction for breast reduction. Updated references.

06/15/07

Reformatted guideline.

08/15/07

Annual review; coverage statements maintained, Medicare Advantage section updated, references updated.

11/15/08

Annual review. No change in position statements. Updated references.

10/15/09

Annual review. Maintain position statements. Updated references.

05/15/10

Revised description. Revised position statement; expand medical necessity criteria. Deleted related Internet links. Updated references.

07/01/10

Updated Calculation of Body Surface Area (BSA).

07/15/10

Added requirement for Certificate of Medical Necessity (CMN) and link to CMN form.

09/15/10

Revision to guideline; consisting of formatting changes.

05/15/11

Scheduled review; maintain position statements. Updated references.

07/01/11

Revision; formatting changes.

07/15/12

Revised criteria for clarity regarding the Schnur Sliding Scale; deleted 5% from Schnur Sliding Scale Table. Add link for on-line body surface area calculation. Delete Medicare ICD-9 codes.

09/15/13

Scheduled review; added statement clarifying breast tissue removal. Updated Medicare Advantage program exception and references.

10/15/14

Scheduled review; maintain position statements. Updated references.

10/15/15

Scheduled review; maintain position statements. Updated references.

Date Printed: June 23, 2017: 11:44 AM