Date Printed: May 25, 2018: 05:12 AM

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Subject: Reduction Mammoplasty

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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.



Reduction mammoplasty is a surgery intended to make enlarged breasts smaller. A surgeon removes sections of skin and breast tissue to reduce breast size. This may help relieve pain, numbness, skin irritation and other problems. The procedure may also help improve a person’s appearance after a mastectomy.

Visit the Clinical View of this guideline for more information.

Visit WebMD for more information on reduction mammoplasty.



Note: For all medical decisions about this service, Florida Blue uses the Position Statement in the Clinical View of this medical coverage guideline. To make the best decision for your health needs, talk to your doctor. The services covered vary from health plan to health plan. Refer to your health plan contract for complete information about your coverage.


Reduction mammoplasty may be covered if certain requirements such as the following are met:

• Back pain

• Neck pain

• Shoulder pain

• Unusual sensations in the arms or hands

• Headache

• Irritation in skin folds

• Shoulder grooving from bra straps

• Mastectomy

For a reduction mammoplasty to be covered, your surgeon must also plan to remove a certain amount of breast tissue. Your doctor’s decision will be based on a special measure called the Schnur Sliding Scale. The scale uses a formula and your total body surface area, or BSA, to show how much breast tissue to remove.

Also, after a mastectomy due to disease in one breast, a reduction mammoplasty may be covered for the other breast to help provide a more normal appearance.

All requests for reduction mammoplasty must properly document:

• Total body surface area

• The amount of tissue to be removed in grams

Photographs should be made available to Florida Blue on request.

Reduction mammoplasty is not considered medically necessary for:

• cosmetic reasons

• correcting previous cosmetic surgery

• otherwise improving appearance in the absence of functional problems

Visit the Clinical View of this guideline for specific coverage information.


• Federal Employee Program (FEP): Certain exceptions apply.

• State Account Organization (SAO): Certain exceptions apply.

• Medicare Advantage products: Certain exceptions apply.

Visit the Clinical View of this guideline for more coverage information.

Refer to your health plan contract for complete information about your coverage.

Date Printed: May 25, 2018: 05:12 AM