Prior Authorization Required

Prior authorization is required for covered reduction mammaplasty (CPT 19318) and related procedures. Coverage determinations are contingent on meeting the policy's selection criteria and supporting documentation.

• Prior authorization required for CPT 19318 (reduction mammaplasty) and related covered codes.
• Coverage contingent on meeting medical-necessity criteria and submission of required documentation (see appendices).

Assess Surgical Risk Factors During Authorization

Authorization review must include assessment of preoperative surgical risk factors that influence complication rates and outcomes. Consider BMI, tobacco use, comorbidities (e.g., dyspnea), inpatient vs outpatient setting, age, and other factors that increase perioperative risk.

• Evaluate BMI and obesity class (higher classes associated with increased complications).
• Document active smoking status and counseling/cessation efforts.
• Note whether procedure planned inpatient vs outpatient and assess dyspnea/other comorbidities.

Use Appendix BSA-to-Tissue-Weight Table

Use the Appendix BSA-to-tissue-weight Table (Table 1) to estimate the minimum grams of breast tissue expected to be removed per breast when applying tissue-weight thresholds for medical necessity.

• Calculate body surface area (Mosteller formula) and reference Table 1 for the corresponding grams per breast.
• If estimated removal per breast exceeds 1,000 g for medical necessity determinations, follow the policy notes in section I.

Authorization Must Reference Policy Appendices

Prior authorization must reference the policy criteria and supporting appendices. Submitted materials should explicitly cite the relevant appendix table(s) and grading scales used in the medical-necessity determination.

• Reference Appendix Table 1 (BSA-to-grams) when tissue-weight thresholds are used.
• Reference gynecomastia drug/exposure list (Appendix) and ASPS gynecomastia grade when applicable.

Cosmetic Exclusions

Procedures performed when policy indications are not met are considered cosmetic and are excluded from coverage. Reduction mammoplasty for asymptomatic members or for indications not listed as medically necessary is not covered.

• Reduction mammaplasty for asymptomatic breasts or indications outside section I are cosmetic and excluded.
• Gynecomastia surgery is considered cosmetic unless reversible causes have been evaluated and medical-necessity criteria are satisfied.

Timing Relative to Breast Maturity

Delay authorization for adolescents until breast growth has ceased and size has been stable for at least 12 months; for adults, document that growth is complete when applicable.

• For adolescents, confirm breasts stopped growing and size stable ≥ 12 months.
• If growth not complete or stability not documented, authorization may be denied as premature.

Irradiated Breast: Increased Complication Risk

Reduction mammoplasty or mastopexy in previously irradiated breasts carries a substantially increased risk of complications. Authorization should document prior radiation and include detailed risk counseling; high-risk cases may be denied if expected complication risk is unacceptable.

• Document history of ipsilateral breast irradiation and discuss increased complication rates.
• Include surgeon assessment of risk/benefit and informed consent acknowledging higher complication rate in irradiated breast.

Preoperative Documentation

Preoperative documentation required with authorization includes the surgeon's estimate of tissue weight to be removed (per breast) based on BSA, high-quality frontal and side photographs, and clinical findings supporting symptomatic indications.

• Surgeon-estimated grams to be removed per breast, calculated from BSA table (Mosteller formula).
• High-quality color frontal and side-view photographs showing breast hypertrophy.
• Clinical documentation linking symptoms to macromastia and prior conservative therapy trials.

Tissue Weight and BSA Reference

Providers must document body surface area (BSA), estimated tissue weight removed per breast (using Appendix Table 1), and gynecomastia grade when applicable; these elements are used to apply the policy thresholds.

• BSA calculation method (Mosteller) and numeric BSA value.
• Estimated grams removed per breast from Appendix Table 1.
• Gynecomastia grade per ASPS scale when gynecomastia assessment is relevant.

Medications and Exposures to Document for Gynecomastia

For gynecomastia evaluation, document a detailed medication and exposure history and list drugs/exposures associated with gynecomastia. Correct reversible causes and consider medical therapy prior to surgical referral.

• Include a complete drug history and environmental/occupational estrogen exposure assessment.
• Document use of agents associated with gynecomastia (see Appendix drug list).
• If reversible cause identified, document management (e.g., drug discontinuation) and response.

Required Documentation Elements (See Appendices)

Required documentation elements for authorization include completed conservative-therapy trial documentation, BSA and estimated tissue weight per breast, gynecomastia grade (if applicable), photos/imaging, and operative plan. When reduction is contralateral to cancer, submit histopathology documentation of the specimen per policy.

• Documentation of ≥ 3-month trial of conservative therapies (analgesics/NSAIDs, physical therapy, supportive devices, dermatologic care, weight-loss program, specialist evaluations).
• BSA calculation and estimated grams to be removed per breast (Appendix Table 1).
• High-quality preoperative photographs and imaging as appropriate.
• Gynecomastia grade (ASPS) and laboratory/imaging work-up if gynecomastia.
• Histopathology report for contralateral reductions performed in the setting of breast cancer.

Evaluation and Conservative Management Prior to Surgery

Evaluation and conservative management must be completed prior to surgical consideration for gynecomastia. Work-up should include laboratory testing and imaging to identify reversible causes and a trial of medical/conservative therapy where appropriate.

• Obtain detailed drug history, testicular exam, and labs (liver, thyroid, gonadotropins, hCG, testosterone, estradiol, DHEAS).
• Imaging as indicated (testicular ultrasound, adrenal imaging) to identify lesions.
• Treat reversible causes and document response; surgical removal is rarely indicated without failed conservative management.

Consider Medical Therapy Trial for Gynecomastia

A trial of medical therapy (e.g., tamoxifen) may be considered for idiopathic gynecomastia prior to surgery given evidence of high resolution rates; document duration, dose, and response.

• Consider tamoxifen 10 mg daily trial and document clinical response and adverse effects.
• If medical therapy leads to resolution, surgery is not indicated; if no response, include documentation of failed medical therapy when requesting authorization.