Covered without prior authorization (high confidence)
Documentation Required
For reduction mammoplasty, the medical record must include height and weight of the beneficiary.
For reduction mammoplasty, include a clinical evaluation documenting signs and/or symptoms ascribed to macromastia, therapies tried prior to surgery, and responses to those therapies.
For reduction mammoplasty, document severity and impact on health-related quality of life using an accepted breast-specific questionnaire.
Operative report must document the weight of tissue removed from each breast (measured in the operating room) and the pathology report for tissue removed must be included in the record.
Key Coverage Criteria
Reconstructive plastic surgery is covered when performed for therapeutic purposes such as treatment of severe burns, facial repair following auto trauma, or similar reconstructive/therapeutic surgery.
Reduction mammoplasty is covered when the beneficiary has symptomatic breast hypertrophy (macromastia) with documented severe symptoms and demonstrable adverse impact on health-related quality of life as measured by an accepted breast-specific questionnaire, AND persistent signs/symptoms despite a reasonable trial of conservative therapy.
The complete medical record must be made available to Medicare or a Medicare auditor upon request; when requesting written redetermination include all relevant documentation or denial is likely.
High-quality photographs are optional but may be submitted when the provider deems them useful to determine medical necessity.