Reduction Mammaplasty

Jurisdiction: JK MAC Part B. States: Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, Vermont. Type: Active LCD

Abstract: Reduction mammaplasty is the surgical removal of a substantial portion of the breast, including the skin and underlying glandular tissue, until a clinically normal size is obtained. Breasts are pair organs, and breast hypertrophy generally affects both sides, therefore, bilateral surgery is usually performed. Reduction mammaplasty is performed to reduce the size of the breasts and help ameliorate symptoms caused by the hypertrophy and to reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery. Indications: Reduction mammaplasty is considered medically necessary: When the patient has significant symptoms that have interfered with normal daily activities, despite conservative management, for at least 6 months, including at least one of the following criteria: History of back and/or shoulder pain which adversely affects activities of daily living (ADLs) unrelieved by, e.g.: conservative analgesia (e.g., such as NSAID, compresses, massage, etc.) supportive measures (e.g., such as garments, back brace, etc.), physical therapy correction of obesity History of significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity, e.g.: Signs and symptoms of ulnar paresthesias Cervicalgia Torticollis Acquired kyphosis Signs and symptoms of: intertriginous maceration or infection of the inframammary skin (e.g., hyperpigmentation, bleeding, chronic moisture, and evidence of skin breakdown), refractory to dermatologic measures, or shoulder grooving with skin irritation (e.g., areas of excoriation and breakdown) by appropriate supporting garment AND Considerable attention has been given to the amount of breast tissue removed in differentiating between cosmetic and medically necessary reduction mammoplasty. To be considered a non-cosmetic procedure it is expected that at least a minimal amount of breast tissue will be removed. Yet, arbitrary minimum weight breast tissue removed criteria do not consistently reflect the consequences of mammary hypertrophy in individuals with a unique body habitus. There are wide variations in the range of height, weight, and associated breast size that cause symptoms. The amount of tissue that must be removed in order to relieve symptoms will vary and depend upon these variations. The following are guidelines (not rules) that address the patient's body surface area (BSA) and the amount of breast tissue removed BSA 1.35-1.45 199-238 BSA 1.46-1.55 239-284 BSA 1.56-1.69 285-349 Equal to or greater than 350g Limitations of Coverage: 1. Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit. 2. Indications of Coverage must be met. Note: Reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is considered a non-cosmetic procedure. National coverage provides for payment of breast reconstruction surgery following removal of a breast for any medical reason.