Reduction Mammaplasty (Non-Cancerous) (Reduction Mammoplasty)
DESCRIPTION
Reduction mammaplasty is the surgical removal of a substantial portion of the breast, including skin and underlying glandular tissue. This surgery is intended to relieve some of the clinical symptoms associated with macromastia. Macromastia is defined as breast enlargement that is significantly disproportionate to the individual's body surface area. Physical symptoms, such as recurrent skin infections, ulcerations, and pain in the upper back and shoulders may result from breast enlargement.
POLICY
Reduction mammaplasty for the treatment of macromastia is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Reduction mammaplasty for the treatment of other conditions/diseases is considered cosmetic.
See also:
MEDICAL APPROPRIATENESS
Reduction mammaplasty is considered medically appropriate if ALL of the following criteria are met:
The average grams of tissue removed per breast falls above the 22nd percentile on the Schnur Sliding Scale chart, relative to the individual's body surface area (BSA) Does Not Apply to TennCare.
Documentation from a treating physician, other than the plastic surgeon, of a minimum 6-week history of ANY ONE of the following:
Recurrent skin infections
Ulcerations
Progressive musculoskeletal symptoms resultant from the weight of the breast that have persisted despite conservative treatment (e.g., appropriate bra support, exercises, heat/cold treatment, or non-steroidal anti-inflammatory agents)
Other potential causes of pain and musculoskeletal damage have been ruled out
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
Published scientific evidence in the form of well-controlled studies in peer-review journals is lacking regarding the use of reduction mammaplasty for other conditions/diseases.
SOURCES
American Society of Plastic Surgeons. (2008). Breast reduction. Retrieved October 27, 2008 from http://www.plasticsurgery.org/patients_consumers/procedures/ReductionMammaplasty.cfm.
BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2003). Reduction mammaplasty (7.01.21). Retrieved June 1, 2010 from BlueWeb. (9 articles and/or guidelines reviewed)
Chadbourne, E. B., Zhang, S., Gordon, M. J., Ro, E. Y., Ross, S. D, Schnur, P. L., et al. (2001). Clinical outcomes in reduction mammaplasty: A systematic review and meta-analysis of published studies. Mayo Clinic Proceedings, 76 (5), 503-510.
Tepper, O. M., Small, K., Rudolph, L., Choi, M., & Karp, N. (2006). Virtual 3-dimensional modeling as a valuable adjunct to aesthetic and reconstructive breast surgery. American Journal of Surgery, 192 (4), 548–551.
Wolfram, D., Pulzl, P., Schoeller, T., & Wechselberger, G. (2006). Reduction mammaplasty and axillary-subclavian venous thrombosis. American Journal of Surgery, 192 (1), 98-99.
ORIGINAL EFFECTIVE DATE: 1/1/1997
MOST RECENT REVIEW DATE: 7/22/2010
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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