Breast Augmentation / Mammaplasty (Non-Cancerous)
Breast augmentation / mammaplasty is a procedure used to correct breast hypoplasia or agenesis. Hypoplasia is defined as the underdevelopment or incomplete development of a tissue or organ. Agenesis is defined as lack of development. These conditions can occur unilaterally or bilaterally and may be congenital or acquired. Some of the more common deformities indicated for breast reconstruction surgery includes Poland’s Syndrome and tuberous breast(s).
Breast augmentation/mammaplasty is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Breast augmentation for non-cancerous bilateral agenesis or marked hypoplasia is considered cosmetic.
Surgery to correct inverted nipples is not considered breast augmentation, and is considered cosmetic.
Breast augmentation/mammaplasty is considered medically appropriate if ALL of the following criteria are met:
Unilateral agenesis or hypoplasia
No diagnosis of breast cancer
Augmentation is performed on the affected breast
Photographs (preferably color) reveal significant deformities/asymmetry beyond normal variations
Any specific products referenced in this policy are just examples and are intended for illustrative purposes 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. These examples are contained in the parenthetical e.g. statement.
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.
TN State Mandate addressing reconstructive breast surgery applies to services rendered following mastectomy and does not apply to this policy.
American Academy of Plastic Surgeons. (2004). Non-cancer related breast reconstruction. Retrieved February 28, 2014 from http://www.plasticsurgery.org/for-medical-professionals/quality-and-health-policy/evidence-based-medicine-guidelines.html.
Brault, N., Stivala, A., Guillier, D., Moris, V., Revol, M., Francois, C., & Cristofari, S. (2017). Correction of tuberous breast deformity: a retrospective study comparing lipofilling versus breast implant augmentation. Journal of Plastic, Reconstruction and Aesthetic Surgery, 70 (5), 585-595. Abstract retrieved April 20, 2017 from PubMed database.
Klinger, M., Caviggioli, F.,Giannasi, S., Bandi, V., Banzatti, B., Veronesi, A. (2016). The prevalence of tuberous/constricted breast deformity in population and in breast augmentation and reduction mammaplasty patients. Aesthetic Plastic Surgery. 2016 June 6. [Epub ahead of print] Abstract retrieved July 6, 2016 from PubMed database.
Palmetto Government Benefit Administrators. (2018, February). LCD for cosmetic and reconstructive surgery (L33428). Retrieved March 12, 2018 from www.cms.gov.
Winocour, S., & Lemaine, V. (2013). Hypoplastic breast anomalies in the female adolescent breast. Seminars in Plastic Surgery, 27 (1), 42-48. (Level 5 evidence)
ORIGINAL EFFECTIVE DATE: 1/11/1983
MOST RECENT REVIEW DATE: 4/12/2018
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.
This document has been classified as public information.