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Date Printed: December 16, 2017: 09:31 PM

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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.

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.

 

DESCRIPTION

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.

COVERAGE

 

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.

PROGRAM EXCEPTIONS

• 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: December 16, 2017: 09:31 PM