MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Reduction Mammoplasty for Breast-related Symptoms

Number 7.01.503

Effective Date January 21, 2014

Revision Date(s) 01/13/14; 01/14/13; 08/14/12; 09/13/11; 11/09/10; 03/10/09; 10/14/08; 02/12/08; 02/13/07; 02/14/06; 02/08/05; 03/09/04; 04/15/03; 07/01/02; 09/21/00; 06/01/99; 04/14/98; 11/05/97

Replaces 7.01.21

Policy

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Reduction mammoplasty may be considered medically necessary for the treatment of macromastia when ALL of the following criteria are met:

  • There are well-documented physical functional impairment symptoms for at least 6-months duration; (for example, shoulder, neck or back pain, or recurrent intertrigo in mammary folds AND
  • The physical functional impairment has not resolved with appropriate conservative therapy (for example, weight loss, appropriate support bra, exercise/physical therapy, heat/cold treatment; appropriate non-steroidal anti-inflammatory drugs/muscle relaxants, and others); AND
  • The amount of breast tissue to be removed meets the minimum weight (in grams) listed in the sliding scale in the policy guidelines. (See the Policy Guidelines section.)

Note: In the case of significant asymmetry, the amount of breast tissue removed from the larger breast must meet the minimum grams listed in the sliding scale.

Reduction mammoplasty is considered not medically necessary in the absence of a demonstrated physical functional impairment or when the grams of breast tissue removed does not meet the sliding scale minimum amount.

Note: Subsequent requests for a reduction mammoplasty for the same patient should be referred to a medical director for review.

Related Policies

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7.01.533

Reconstructive Breast Surgery/Management of Breast Implants

10.01.514

Cosmetic and Reconstructive Services

Policy Guidelines

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The presence of shoulder, neck, or back pain is the most common medical rationale that is stated for reduction mammoplasty. However, since these symptoms are subjective, the Schnur sliding scale, based on the patient’s body surface area (BSA)*, is the criteria used for a more objective measure in this medical policy.

Body Surface Area (m2)* and Weight of Breast Tissue Removed [per breast]

Body Surface Area (m2)

Minimum Grams of Breast Tissue to be Removed

1.35

199

1.40

218

1.45

238

1.50

260

1.55

284

1.60

310

1.65

338

1.70

370

1.75

404

1.80

441

1.85

482

1.90

527

1.95

575

2.00

628

2.05

687

2.10

750

2.15

819

2.20

895

2.25

978

2.30

1,068

2.35

1,167

2.40

1,275

2.45

1,393

2.50

1,522

2.55

1,662

*Calculation of Body Surface Area (BSA)

  • Body surface area = the square root of height (cm) multiplied by weight (kg) divided by 3,600.
  • To convert pounds to kilograms, multiply pounds by 0.45
  • To convert inches to meters, multiply inches by 0.0254

Click the hyperlink for an online BSA calculator : http://www.medcalc.com/body.html

Note: The scale above is taken from the Schnur Sliding Scale and shows the BSA and associated grams of breast tissue to be removed to meet the 22nd percentile where women are likely to have a reduction mammoplasty primarily for medical reasons.

In determining the medical necessity of the reduction mammoplasty, the number of grams of breast tissue to be removed should be used as a guideline, along with the severity and duration of the breast-related symptoms and response or failure of conservative interventions.

Occasionally, a second reduction mammoplasty may be performed on an individual, particularly if the individual has experienced weight gain after the original reduction mammoplasty. Requests to perform a second procedure require medical director review.

Description

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Reduction mammoplasty, also known as breast reduction, is a surgical procedure to remove a variable amount of breast tissue to relieve clinical symptoms of physical functional impairment associated with macromastia.

Macromastia or gigantomastia is an ill-defined term that describes breast hyperplasia or hypertrophy that results in the development of abnormally large breasts that are out of proportion to an individual’s body size (body habitus). The weight of very large breasts may result in clinical symptoms such as strain on the shoulders, neck, or back pain, or recurrent intertrigo in the mammary folds where the breast(s) hang against the chest. In addition, macromastia may be associated with psychosocial or emotional disturbances related to large breast size.

Scope

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Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

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Breast reduction surgery (reduction mammoplasty) may be excluded from coverage under some benefit plans. Please consult the member benefit booklet or customer service for related contract language. (See Scope section above.)

Definitions

The following definitions apply to this policy:

Cosmetic: Cosmetic services are those which are primarily intended to preserve or improve appearance. Cosmetic surgery is performed to reshape structures of the body in order to improve the patient’s appearance or self-esteem.

Intertrigo: Recurrent or chronic inflammation that occurs in warm, moist areas of the body where two skin surfaces (skin folds) rub or press against each other (such as between pendulous breasts and the chest wall). It is caused by moisture, bacteria, yeast, or fungus in the folds of the skin. If the skin is stays very moist, it may begin to break down. In severe cases, there may be a bad odor caused by the skin break down.

Physical Functional Impairment: In this policy, functional impairment means a limitation from normal (or baseline level) of physical functioning that may include, but is not limited to, problems with ambulation, mobilization, communication, respiration, eating, swallowing, vision, facial expression, skin integrity, distortion of nearby body parts or obstruction of an orifice. The physical functional impairment can be due to structure, congenital deformity, pain, or other causes. Physical functional impairment excludes social, emotional and psychological impairments or potential impairments.

Reconstructive Surgery: In this policy, reconstructive surgery refers to surgeries performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function.

Rationale

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This policy was originally created in 1997 and has been updated based on searches of the MEDLINE database. The most recent literature search was performed for the period of September 2012 through September 2013. The following is a summary of the key findings since the policy was created to date.

While the literature search identified several articles that discuss the surgical technique of reduction mammoplasty and document that reduction mammoplasty is associated with a relief of physical and psychosocial symptoms, (1-9) the medical policy has always focused on the distinction of whether the proposed reduction mammoplasty is medically necessary or cosmetic in nature. For some patients the presence of medical indications is clear-cut, i.e., a clear documentation of recurrent intertrigo, or ulceration secondary to shoulder grooving. However, for the majority of patients, the documentation between a cosmetic and medically necessary procedure will be unclear and subjective in nature. Criteria for medically necessary reduction mammoplasty are not well addressed in the published medical literature, and thus the optimal patient selection criteria cannot rely on an evidence-based approach.

Breast Weight

The following discussion focuses on the published literature addressing the use of weight of excised breast tissue as coverage criteria.

In 2001, Krieger and colleagues reported on a survey of managed care policies regarding reduction mammoplasty (10). Most of the respondents to the survey stated that they use weight of excised tissue as the main criterion for allowing the procedure. The average cut-off value for this determination was 472 g. While 500 g. appears to be a commonly cited cut-off weight of excised tissue, there appears to be no documentation in the literature as to the sensitivity and specificity of this value in distinguishing cosmetic from medically necessary procedures. (11) Also, the use of a single weight cut-off does not address the issue of the relationship between body surface area and weight of excised tissue.

In 1991, Schnur and colleagues, at the request of third party payers, developed a sliding scale. (11) This sliding scale was based on survey responses of 92 of 200 solicited plastic surgeons, who reported the height, weight, and amount of breast tissue removed from each breast from the last 15 to 20 reduction mammaplasties that had been performed. The 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 according to the 5th percentile and 22nd percentile lines. Based on their estimates, those with breast weight above the 22nd percentile line likely had the procedure performed for medical reasons, while those below the 5th percentile line likely had the procedure performed for cosmetic reasons, and those falling between the lines had the procedure performed for mixed reasons.

In 1999, Schnur reviewed the experience of the sliding scale as a coverage criterion, and reported that while many payers had adopted this scale, many had also misused it. (12) The author pointed out that if a payer uses weight of resected tissue as a coverage criterion, then if the weight falls below the 5th percentile line the reduction mammoplasty would be considered cosmetic, above the 22nd percentile line it would be considered medically necessary, and those that fall between these lines would be considered on a case by case basis. The author also questions the frequent requirement that a woman be within 20% of her ideal body weight. While weight loss might indeed relieve symptoms, durable weight loss is notoriously difficult and may be unrealistic in many cases. However, in 2003, Platt and colleagues reported on a prospective study of 30 women which found wound breakdown was significantly greater in women with a body mass index (BMI) of 26.3 or greater (33%) compared to BMI of less than 26.3 (10%). (13) Delayed healing was also associated with high BMI.

Kocak and colleagues noted that previous formulas for predicting resected tissue weights have been inconsistent and particularly unreliable in smaller reductions. Kocak stated that his study described a dependable, surgeon-specific method based on two simple preoperative measurements to estimate tissue resection weights in patients undergoing reduction mammoplasty. He reviewed the medical charts of 72 consecutive patients who underwent reduction mammoplasty. Preoperatively-obtained measurements from the first 15 patients were plotted against the actual corresponding amount of breast tissue removed at the time of surgery. Linear regression of this plot was used to generate a mathematical formula that was then used to predict resection weights of the subsequent 57 patients. The results were compared with the actual weights recorded intraoperatively. Several measurements were evaluated and Pearson coefficients generated. He found that the mathematical product of two unique breast-only surface measurements along horizontal and vertical planes generated the linear regression formula with the greatest accuracy (r = 0.95) for predicting the weight of tissue to be resected compared with either measurement alone or sternal notch-to-nipple distance. (14) He concluded that by using two simple preoperative measurements correlated with tissue resection weights in a small series of procedures, any reconstructive surgeon can create his or her own reliable formula for predicting breast tissue resection weights for reduction mammoplasty.

In 2012, Gonzalez and colleagues reported on 178 patients who had breast reduction surgery primarily for symptomatic macromastia. Patients completed the Breast Q questionnaire once after surgery, and retrospective chart reviews were completed to assess patient outcomes and determine whether any correlation exists between outcomes and patient size or amount of breast tissue removed. (15) Most patients responded to the surgery with satisfaction with a mean response on the Breast Q questionnaire of 2.8 (2, somewhat agree; 3, definitely agree). The mean BMI of patients was 28.3 kg/m and correlated significantly with the amount of breast tissue removed (p<0.0001). The mean amount of breast tissue removed was 1,220.9 g but did not correlate significantly with patient quality-of-life responses (p=0.57).

Functional Impairment

Singh and Losken, in 2012, reported on a systematic review of studies reporting outcomes after reduction mammoplasty. (16) The reviewers found reduction mammoplasty improves functional outcomes including pain, breathing, sleep, and headaches. Additional psychological outcomes noted in the review include improvements in self-esteem, sexual function, and quality of life.

In 2002, Kerrigan and Collins published the results of the BRAVO (Breast Reduction: Assessment of Value and Outcomes) study, a registry of 179 women undergoing reduction mammoplasty. (17) Women were asked to complete quality of life questionnaires and a physical symptom count both before and after surgery. The physical symptom count focused on the number of symptoms present that were specific to breast hypertrophy and included upper back pain, rashes, bra strap grooves, neck pain, shoulder pain, numbness and arm pain. In addition, the weight and volume of resected tissue were recorded. Results were compared to a control group of patients with breast hypertrophy, defined as size DD bra cup, and normal sized breasts, who were recruited from the general population. The authors propose that the presence of 2 physical symptoms might be an appropriate cut-off for determining medical necessity for breast reduction. For example, while 71.6% of the hypertrophic controls reported none or one symptom, only 12.4% of those considered surgical candidates reported none or one symptom. This observation is difficult to evaluate because the study does not report how surgical candidacy was determined. The authors also reported that none of the traditional criteria for determining medical necessity for breast reduction surgery (height, weight, body mass index, bra cup size, or weight of resected breast tissue) had a statistically significant relationship with outcome improvement. The authors conclude that the determination of medical necessity should be based on patients’ self-reports of symptoms rather than more objectively measured criteria, such as weight of excised breast tissue.

In 2008, Sabino Neto et al, reported on a study to assess functional capacity in which 100 patients, ages 18-55 years, were randomized to receive reduction mammoplasty or be placed on a waiting list to serve as a control group. (7) Patient exclusion criteria included body mass index greater than 30 kg/m², asymmetry in mammary hypertrophy, chronic disease, smoking, or daily medication use. Forty-six patients from each group completed the study. At the onset of the study and 6 months later, patients were assessed for functional capacity using the Roland-Morris instrument (0=best performance, 24=worst performance) and for pain using a visual analog scale (VAS). The reduction mammoplasty group showed improvement in functional status with an average score of 5.9 preoperatively to 1.2 within 6 months postoperatively (p<0.001 for pre- post-comparison within the mammoplasty group) versus an unchanged average score of 6.2 in the control group on the first and second evaluations. Additionally, pain in the lower back region decreased on VAS from an average of 5.7 preoperatively to 1.3 postoperatively (p<0.001 for pre- post-comparison within mammoplasty group) versus VAS average scores in the control group of 6.0 and 5.3 on the first and second evaluations, respectively (no significant change). Three patients did not report any improvement in low back pain after surgery. The authors noted a need for exercise programs after surgery to improve posture malposition that developed after years of mammary hypertrophy.

Also in 2008, Saariniemi and colleagues reported on a study to assess quality of life and pain in which 82 patients were randomized to reduction mammoplasty or a non-operative group in which patients were evaluated at the onset of the study and 6 months later. (9) The authors reported the mammoplasty group had significant improvements in quality of life, as measured by the physical summary score of the Short Form (SF)-36 quality-of-life questionnaire (change of +9.7 vs. +0.7, p<0.0001), the utility index score (SF-6D) (+17.5 vs. +0.6)., the index score of quality of life (SF-15D) (+8.6 vs. +0.06, p<0.0001), and the SF-36 mental summary score (+7.8 vs. -1.0, p<0.002). There were also improvements in breast-related symptoms, as measured by the Finnish Breast-Associated Symptoms questionnaire score (-47.9 vs. -3.5, p<0.0001), and the Finnish Pain Questionnaire score (-21.5 vs. -1.0, p<0.0001).

Iwuagwu et al. reported in 2006 on 73 patients randomized to receive reduction mammoplasty within 6 weeks or after a 6-month waiting period to assess lung function. (8) All patients had symptoms related to macromastia. Postoperative lung function correlated with the weight of breast tissue removed, but there were no significant improvements in any lung function parameters for the mammoplasty group compared to control. This is in contrast to previous studies, such as Cunha et al. who reported improvements in lung function after reduction mammoplasty in 12 patients followed prospectively in a cohort study. (18) Arterial blood gases did not differ significantly pre- or postoperatively.

Complications

Thibaudeau and colleagues, in 2010, conducted a systematic review to evaluate breastfeeding after reduction mammoplasty. (19) After a review of literature from 1950 through December 2008, the authors concluded reduction mammoplasty does not reduce the ability to breastfeed. In women who have had reduction mammoplasty, breastfeeding was found to be comparable for the first month postpartum in the general population in North America.

In 2011, Chen and colleagues reported on a review of claims data to compare complication rates after breast surgery in 2,403 obese and 5,597 non-obese patients. (20) Of these patients, breast reduction was performed in 1,939 (80.7%) in the study group and 3,569 (63.8%) in the control group. Obese patients had significantly more claims for complications within 30 days after breast reduction surgery than non-obese patients (14.6% vs. 1.7%, respectively, p<0.001). Complications included inflammation, infection, pain and seroma/hematoma development. Also in 2011, Shermak et al. reported on a review of claims data to compare complication rates in relation to age after breast reduction surgery in 1,192 patients. (21) Infection occurred more frequently in patients older than 50 years of age [odds ratio (OR): 2.7; p=0.003]. Additionally, women older than 50 years also experienced more wound healing problems (OR: 1.6; p=0.09) and reoperative wound debridement (OR: 5.1; p=0.07).

Ongoing Clinical Trials

A previously reported ongoing trial (online site ClinicalTrials.gov NCT01297621) randomized 60 patients to evaluate patient satisfaction, sexuality, and physical activity outcomes after reduction mammoplasty was completed in June 2013. As of October 9, 2013 there were no reported results for this study, which was carried out in Brazil, and there were no additional active clinical trials that addressed functional outcomes for reduction mammoplasty.

Summary

Reduction mammoplasty is a surgical procedure designed to remove a variable proportion of breast tissue. The available evidence from randomized controlled and prospective studies indicates that reduction mammoplasty 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 following reduction mammoplasty. Therefore, the available evidence for reduction mammoplasty is sufficient to demonstrate improvements in net health outcomes and may be considered medically necessary when the criteria in the policy statement are met.

Practice Guidelines and Position Statements

The American Society of Plastic Surgeons (ASPS) issued practice guidelines and a companion document on criteria for third-party payers for reduction mammoplasty. (22-24) The ASPS indicates level I evidence has shown reduction mammoplasty is effective in treating symptomatic breast hypertrophy which “is defined as a syndrome of persistent neck and shoulder pain, painful shoulder grooving from brassiere straps, chronic intertriginous rash of the inframammary fold, and frequent episodes of headache, backache, and neuropathies caused by heavy breasts caused by an increase in the volume and weight of breast tissue beyond normal proportions.” The ASPS also indicates volume or weight of breast tissue resection should not be criteria for reduction mammoplasty. If 2 or more symptoms are present all or most of the time, reduction mammoplasty is appropriate.

While criteria for medically necessary reduction mammoplasty are not well addressed in the published medical literature, a method of considering both severity of symptoms and number of grams of breast tissue to be removed remains the optimum practice for determining medical necessity.

Medicare National Coverage

There is no national coverage determination.

References

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  1. Dabbah A, Lehman JA, Parker MG et al. Reduction mammoplasty: an outcome analysis. Ann Plast Surg 1995; 35(4):337-41.
  2. Schnur PL, Schnur DP, Petty PM et al. Reduction mammoplasty: an outcome study. Plast Reconstr Surg 1997; 100(4):875-83.
  3. Hidalgo DA, Elliot LF, Palumbo S et al. Current trends in breast reduction. Plas Reconstr Surg 1999; 104(3):806-18.
  4. Glatt BS, Sarwer DB, O’Hara DE et al. A retrospective study of changes in physical symptoms and body image after reduction mammoplasty. Plast Reconstr Surg 1999; 103(1):76085.
  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 2002; 109(5):1556-66.
  6. Iwuagwu OC, Walker LG, Stanley PW et al. Randomized clinical trial examining psychosocial and quality of life benefits of bilateral breast reduction surgery. Br J Surg 2006; 93(3):291-4.
  7. Sabino Neto M, Dematte MF, Freire M et al. Self-esteem and functional capacity outcomes following reduction mammoplasty. Aesthet Surg J 2008; 28(4):417-20.
  8. Iwuagwu OC, Platt AJ, Stanley PW et al. Does reduction mammoplasty improve lung function test in women with macromastia? Results of a randomized controlled trial. Plast Reconstr Surg 2006; 118(1):1-6; discussion 7.
  9. Saariniemi KM, Keranen UH, Salminen-Peltola PK et al. Reduction mammoplasty is effective treatment according to two quality of life instruments. A prospective randomised clinical trial. J Plast Reconstr Aesthet Surg 2008; 61(12):1472-8.
  10. Krieger LM, Lesavoy MA. Managed care’s methods for determining coverage of plastic surgery procedures: the example of reduction mammoplasty. Plast Reconstr Surg 2001; 107(5):1234-40.
  11. Schnur, PL, Hoehn JG, Ilstrup DM et al. Reduction mammoplasty: Cosmetic or reconstructive procedure? Annals of Plastic Surgery 1991; 27:232-237.
  12. Schnur, PL. Reduction mammoplasty – the Schnur Sliding Scale revisited. Ann Plast Surg 1999; 42(1):107-8Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. Reduction mammoplasty: The need for prospective randomized studies. Plast Reconstr Surg. 2004; 113(1):436-437.
  13. Platt AJ, Mohan D, Baguley P. The effect of body mass index and wound irrigation on outcome after bilateral breast reduction. Ann Plast Surg 2003; 51(6):552-5.
  14. Kocak E, Carruthers KH, McMahan JD. A reliable method for the preoperative estimation of tissue to be removed during reduction mammoplasty. Plast Reconstr Surg. 2011;127(3):1059-64.
  15. Gonzalez MA, Glickman LT, Aladegbami B et al. Quality of life after breast reduction surgery: a 10-year retrospective analysis using the breast q questionnaire: does breast size matter? Ann Plast Surg 2012; 69(4):361-3.
  16. Singh KA, Losken A. Additional benefits of reduction mammoplasty: a systematic review of the literature. Plast Reconstr Surg 2012; 129(3):562-70.American Society of Plastic Surgeons. Reduction Mammoplasty Criteria for Third-Party Payer. March 2002. Last accessed August 2, 2012.
  17. Kerrigan CL, Collins ED, Kim HM et al. Reduction mammoplasty: defining medical necessity. Med Decis Making 2002; 22(3):208-17.
  18. Cunha MS, Santos LL, Viana AA et al. Evaluation of pulmonary function in patients submitted to reduction mammoplasty. Rev Col Bras Cir 2011; 38(1):11-4.
  19. Thibaudeau S, Sinno H, Williams B. The effects of breast reduction on successful breastfeeding: a systematic review. J Plast Reconstr Aesthet Surg 2010; 63(10):1688-93.Appel JZ 3rd, Wendel JJ, Zellner EG et al. Association between preoperative measurements and resection weight in patients undergoing reduction mammoplasty. Ann Plast Surg. 2010;64(5):512-5.
  20. Chen CL, Shore AD, Johns R et al. The impact of obesity on breast surgery complications. Plast Reconstr Surg 2011; 128(5):395e-402e.
  21. Shermak MA, Chang D, Buretta K et al. Increasing age impairs outcomes in breast reduction surgery. Plast Reconstr Surg 2011; 128(6):1182-7.
  22. American Society of Plastic Surgeons. Reduction Mammoplasty: ASPS Recommended Insurance Coverage Criteria for Third-Party Payers. 2011. Available online at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/insurance/Reduction_Mammaplasty_Coverage_Criteria.pdf. Last accessed December 27, 2012.
  23. American Society of Plastic Surgeons. Evidence-based Clinical Practice Guideline: Reduction Mammoplasty. Available online at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Reduction_Mammaplasty_Evidence_Based_Guideline%20%282%29%282%29.pdf. Last accessed December 27, 2012.
  24. Kalliainen LK. ASPS Clinical Practice Guideline Summary on Reduction Mammoplasty. Plast Reconstr Surg 2012; 130(4):785-9.
  25. BlueCross BlueShield Association Medical Policy Reference Manual Reduction Mammoplasty for Breast- Related Symptoms. Medical Policy Reference Manual, Policy No. 7.0.21, 2012
 

Coding

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Codes

Number

Description

CPT

19318

Reduction Mammoplasty

ICD-9 Procedure

85.31

Reduction Mammoplasty, unilateral

 

85.32

Bilateral

ICD-9 Diagnosis

611.1

Hypertrophy of breast

 

695.89

Other specified erythematous conditions (shoulder grooving and intertrigo)

 

707.8

Chronic ulcer of other specified sites

 

719.41

Pain in joint, shoulder region

 

724.5

Backache, unspecified

Appendix

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N/A

History

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Date

Reason

01/05/97

New Policy. Add to Surgery section.

04/14/98

Replace Policy. Reviewed with changes

06/01/99

Replace Policy. Expanded Description, changes in Policy and Policy Guidelines

09/21/00

Replace Policy. Criteria for amount of breast tissue to be removed revised.

07/01/02

Replace Policy. Policy description updated, policy guidelines clarified, and references added.

04/15/03

Replace Policy. Policy revised and updated; more detailed discussion on criteria used to distinguish medically necessary from cosmetic procedures.

03/09/04

Replace Policy. Policy reviewed; no change to policy statement; additional references added.

09/01/04

Replace Policy. Policy renumbered from PR.7.01.103. No changes to dates.

02/08/05

Replace Policy. Policy reviewed; no change to policy statement; new references added.

02/14/06

Replace Policy. Policy reviewed; with literature search; no change to policy statement; new references added.

06/06/09

Update Scope and Disclaimer. No other changes.

02/13/07

Replace Policy. Policy updated with literature review. Medically necessary policy statement unchanged but clarified and complimented by a cosmetic policy statement. Definitions for cosmetic, physical functional impairment and reconstructive surgery added to the Policy Guidelines.

02/12/08

Replace Policy. Policy updated with literature search. No change to policy statement. Reference added.

10/14/08

Replace Policy. Policy statement revised from cosmetic to not medically necessary for those not meeting the criteria of physical functional impairment or Schnur Sliding Scale.

03/10/09

Replace Policy. Policy statement revised to include note on significant asymmetry. Policy Guidelines revised by extending Schnur scale to larger BSA and greater corresponding grams, and note added regarding deference to severity of symptoms. Rationale and References updated
Effective November 3, 2009 due to notification process.

11/09/10

Replace Policy. Policy updated with literature search. No change to policy statement. References added.

09/15/11

Replace Policy. Policy updated with literature search. No change to policy statement. Reference added. Related Policies updated; 10.01.514 added.

08/20/12

Replace Policy. Policy updated with literature search. No change to policy statement. Remove Related Policy 9.01.502 as it was deleted.

01/14/13

Replace policy. Title revised with addition of “breast-related symptoms”. Policy statement revised with addition of “6-months duration of symptoms unresponsive to conservative interventions” statements with examples. Added definition of intertrigo to benefit application section. Rationale section updated based on a literature review through September 2012. The word “mammoplasty” is replaced with new spelling mammaplasty throughout the policy. References15, 20-21, 24 added. Others renumbered or removed. Policy statement changed as noted.

09/5/13

Minor update. Change the spelling of “mammaplasty” to “mammoplasty” for purposes of consistency with other terms (e.g., mammography).

01/21/14

Replace policy. Policy updated with literature search. Clinical Trials information updated. No change to policy statement.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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