Medical policy: Reduction Mammoplasty for Breast-Related Symptoms

Policy number: MP 1.013

Effective date: 11/1/2026

Policy

Reduction mammaplasty may be considered medically necessary for the treatment of macromastia when all of the following are met:

• Clinical symptoms are documented of either:
• A minimum 6-week history of shoulder, neck, or back pain related to macromastia not responsive to conservative therapy, such as:
• An appropriate support bra, and
• Exercises, and
• Heat/cold treatment, and
• Medications such as:
  • Appropriate nonsteroidal anti-inflammatory agents or
  • Muscle relaxants; OR
• Recurrent or chronic intertrigo between the pendulous breast and the chest wall.
• Photographic documentation demonstrating breast size and/or associated findings such as shoulder grooving.
• The anticipated amount of breast tissues to be removed is consistent with the Schnur Sliding Scale, based on the individuals body surface area.
• Individual is within 20% of ideal body weight.

Reduction mammoplasty is considered a reconstructive procedure and medically necessary when performed on the unaffected breast following previous radical surgery for disease when the purpose is to provide symmetry with the breast on which the mastectomy has been performed.

Reduction mammoplasty is considered investigational for all other indications not meeting the above criteria as there is insufficient evidence to support a general conclusion concerning the health outcomes or benefits associated with this procedure.

Policy guidelines

The presence of shoulder, neck, or back pain is the most common stated medical rationale for reduction mammaplasty. However, because these symptoms and others may be subjective, various other selection criteria has been designed to be more effective. These criteria include:

• Use of photographs, providing a visual documentation of breast size or documenting the presence of shoulder grooving, an indication that the breast weight results in grooving of the bra straps on the shoulder.
• Requirement of a specified amount of breast tissue to be resected, commonly 500 to 600 grams per breast.
• Use of the Schnur Sliding Scale, which suggests a minimum amount of breast tissue to be removed for the procedure to be considered medically necessary, based on the individual's body surface area.
• Requirement that the individual must be within 20% of ideal body weight to eliminate the possibility that obesity is contributing to the symptoms of neck or back pain.

Cross-references

• MP 1.004 Cosmetic and Reconstructive Surgery
• MP 1.103 Reconstructive Breast Surgery Including Management of Breast Implants, External Breast Prothesis and Post Mastectomy Bras
• MP 1.129 Surgical Treatment of Gynecomastia

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO - Refer to Section VI of the FEP Medical Policy Manual. The FEP Medical Policy Manual can be found at: FEP Medical Policy Manual.

Description/Background

Macromastia

Macromastia, or gigantomastia, is a condition that describes breast hyperplasia or hypertrophy. Macromastia may result in clinical symptoms such as shoulder, neck, or back pain, or recurrent intertrigo in the mammary folds. In addition, macromastia may be associated with psychosocial or emotional disturbances related to the large breast size. Reduction mammoplasty is a surgical procedure designed to remove a variable proportion of breast tissue to address emotional and psychosocial issues and/or to relieve the associated clinical symptoms.

Treatment

Reduction mammoplasty is a surgical procedure designed to remove a variable proportion of breast tissue to address emotional and psychosocial issues and/or relieve the associated clinical symptoms.

While literature searches have identified many articles that discuss the surgical technique of reduction mammaplasty and have documented that reduction mammaplasty is associated with relief of physical and psychosocial symptoms, an important issue is whether reduction mammaplasty is a functional need or cosmetic. For some patients, the presence of medical indications is clear-cut: clear documentation of recurrent intertrigo or ulceration secondary to shoulder grooving. For some patients, the documentation differentiating between a cosmetic and a medically necessary procedure will be unclear. Criteria for medically necessary reduction mammaplasty are not well-addressed in the published medical literature.

Some protocols on the medical necessity of reduction mammaplasty are based on the weight of removed breast tissue. The basis of weight criteria is not related to the outcomes of surgery, but to surgeons retrospectively classifying cases as cosmetic or medically necessary. Schnur et al (1991) at the request of third-party payers, developed a sliding scale. This scale was based on survey responses from 92 of 200 solicited plastic surgeons, who reported the height, weight, and amount of breast tissue removed from each a breast from the last 15 to 20 reduction mammaplasties they had performed. Surgeons were also asked if the procedures were performed for cosmetic or medically necessary reasons. The data were then used to create a chart relating the body surface area, and the cutoff weight of breast tissue removed that differentiated cosmetic and medically necessary procedures. Based on their estimates, those with a breast tissue removed weight above the 22^nd percentile likely had the procedure for medical reasons, while those below the 5^th percentile likely had the procedure performed for cosmetic reasons; those falling between the cutpoints had the procedure performed for mixed reasons.

Schnur (1999) reviewed the use of the sliding scale as a coverage criterion and reported that, while many payers had adopted it, many had also misused it. Schnur pointed out that if a payer used weight of resected tissue as a coverage criterion, then if the weight fell below the 5^th percentile, the reduction mammaplasty would be considered cosmetic; if above the 22^nd percentile, it would be considered medically necessary; and if between these cutpoints, it would be considered on a case-by-case basis. Schnur also questioned the frequent requirement that a woman is within 20% of her ideal body weight. While weight loss might relieve symptoms, durable weight loss is notoriously difficult and might be unrealistic in many cases.

Regulatory status

Reduction mammaplasty is a surgical procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration.

Rationale

Summary of evidence

For individuals who have symptomatic macromastia who receive reduction mammaplasty, the evidence includes systematic reviews of randomized controlled trials, cohort studies, and case series. Relevant outcomes are symptoms and functional outcomes. Studies have indicated that reduction mammaplasty is effective at decreasing breast-related symptoms such as pain and discomfort. There is also evidence that functional limitations related to breast hypertrophy are improved after reduction mammaplasty. These outcomes are achieved with acceptable complication rates. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Definitions

Act 51 of 1997 – The Mastectomy Act: PA mandate that prohibits health insurance companies from requiring mastectomies to be performed on an outpatient basis. Other requirements include coverage for: One home health visit within 48 hours after discharge when the discharge is within 48 hours of the admission for the mastectomy; Reconstructive surgery, including surgery to re-establish symmetry and mastectomy-related prosthetic devices.

Cosmetic surgery: An elective procedure performed primarily to change a person’s appearance by surgically altering a physical characteristic that does not prohibit normal function but is considered unpleasant or unsightly.

Intertrigo: A superficial dermatitis occurring on apposed skin surfaces, such as the axillae, creases of the neck, intergluteal fold, groin, between the toes and beneath pendulous breasts, with obesity being a predisposing factor, caused by moisture, friction, warmth and sweat retention and characterized by erythema, maceration, burning, itching and sometimes erosions, fissures and exudations and secondary infections.

Reconstructive surgery: A procedure performed to improve or correct a functional impairment, restore a bodily function, or correct a deformity resulting from birth defect or accidental injury. The fact that a member might suffer psychological consequences from a deformity does not, in the absence of bodily functional impairment, qualify surgery as being reconstructive surgery.

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as permitted by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These polices are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the members’ benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

Covered when medically necessary

References

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2. Schnur PL, Schnur DP, Petty PM, et al. Reduction mammaplasty: an outcome study. Plast Reconstr Surg. Sep 1997;100(4):875-883. PMID 9290655
3. Hidalgo DA, Elliot LF, Palumbo S, et al. Current trends in breast reduction. Plast Reconstr Surg. Sep 1999;104(3):806-815; quiz 816; discussion 817-808. PMID 10456536
4. 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. Jan 1999;103(1):76-82; discussion 83-75. PMID 9915166
5. Collins ED, Kerrigan CL, Kim M, et al. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plast Reconstr Surg. Apr 15, 2002;109(5):1556-1566. PMID 11932597
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9. Saariniemi KM, Keranen UH, Salminen-Peltola PK, et al. Reduction mammaplasty is effective treatment according to two quality of life instruments. A prospective randomised clinical trial. J Plast Reconstr Aesthet Surg. Dec 2008;61(12):1472-1478. PMID 17983882
10. Schnur PL, Hoehn JG, Ilstrup DM, et al. Reduction mammaplasty: cosmetic or reconstructive procedure? Ann Plast Surg. Sep 1991;27(3):232-237. PMID 1952749
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12. Lin Y, Yang Y, Zhang X, et al. Postoperative Health-related Quality of Life in Reduction Mammaplasty: A Systematic Review and Meta-Analysis. Ann Plast Surg. Jul 01 2021; 87(1): 107-112. PMID 33346564
13. Beraldo FN, Veiga DF, Veiga-Filho J, et al. Sexual Function and Depression Outcomes Among Breast Hypertrophy Patients Undergoing Reduction Mammaplasty: A Randomized Controlled Trial. Ann Plast Surg. Apr 2016; 76(4): 379-82. PMID 25536204
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18. Torresetti M, Zuccatosta L, Di Benedetto G. The effects of breast reduction on pulmonary functions: A systematic review. J Plast Reconstr Aesthet Surg. Dec 2022; 75(12): 4335-4346. PMID 36229312
19. Hernanz F, Fidalgo M, Munoz P, et al. Impact of reduction mammoplasty on the quality of life of obese patients suffering from symptomatic macromastia: A descriptive cohort study. J Plast Reconstr Aesthet Surg. Aug 2016;69(8):e168-173. PMID 27344408
20. Kerrigan CL, Collins ED, Kim HM, et al. Reduction mammaplasty: defining medical necessity. Med Decis Making. May-Jun 2002;22(3):208-217. PMID 12058778
21. Thibaudeau S, Sinno H, Williams B. The effects of breast reduction on successful breastfeeding: a systematic review. J Plast Reconstr Aesthet Surg. Oct 2010;63(10):1688-1693. PMID 19692299
22. Chen CL, Shore AD, Johns R, et al. The impact of obesity on breast surgery complications. Plast Reconstr Surg. Nov 2011;128(5):395e-402e. PMID 21666541
23. Shermak MA, Chang D, Buretta K, et al. Increasing age impairs outcomes in breast reduction surgery. Plast Reconstr Surg. Dec 2011;128(6):1182-1187. PMID 22094737
24. Gust MJ, Smetona JT, Persing JS, et al. The impact of body mass index on reduction mammaplasty: a multicenter analysis of 2492 patients. Aesthet Surg J. Nov 01, 2013;33(8):1140-1147. PMID 24214951
25. Nelson JA, Fischer JP, Chung CU, et al. Obesity and early complications following reduction mammaplasty: An analysis of 4545 patients from the 2005-2011 NSQIP datasets. J Plast Surg Hand Surg. Oct 2014;48(5):334-339. PMID 24506446
26. American Society of Plastic Surgeons. Reduction Mammaplasty: ASPS Recommended Insurance Coverage Criteria for Third-Party Payers. 2021
27. Perdikis G, Dillingham C, Boukovalas S, et al. American Society of Plastic Surgeons Evidence-Based Clinical Practice Guideline Revision: Reduction Mammaplasty. Plast Reconstr Surg. Mar 01 2022; 149(3): 392e-409e. PMID 35006204
28. Pennsylvania General Assembly. Act 51 of 1997. Act of 4 Nov. 1997, P.L. 492, No. 51