Reduction Mammoplasty and Gynecomastia Surgery
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Clinical coverage criteria and guidance for reduction mammoplasty (breast reduction) and gynecomastia surgery for members of the Health Plan (Ambetter Nevada). Affects providers seeking prior authorization and coverage determinations for these procedures.
Clarifying language was added to Criteria I.A. and several subitems (I.A.3, I.A.3.c, I.A.3.g) and criteria II.A.4 requiring adult testicular size was removed.
Removed 'persistent' and 'for at least one year' in Criteria I.A.3.
Removed criteria II.A.4. requiring adult testicular size to be attained.
Coverage Criteria
Revised coverage criteria
Policy criteria revised during annual review; see full policy for exact logic groups.
Criteria I: Reduction Mammoplasty (updated)
- Clarifying language added to Criteria I.A and subitems I.A.3, I.A.3.c, I.A.3.g.
- Removed the terms 'persistent' and 'for at least one year' from Criteria I.A.3 as part of the revision.
See full policy for complete, original criterion text and for operational definitions (Schnur sliding scale, Tanner staging).
Criteria II: Gynecomastia Surgery (updated)
- Criteria II was revised; specifically, criteria II.A.4 requiring adult testicular size to be attained has been removed.
See full policy for complete criterion text and any age- or development-specific requirements.
This clinical policy provides coverage guidance for reduction mammoplasty and gynecomastia surgery for members of the Health Plan. It does not replace or modify a member's contract terms; coverage remains subject to the specific terms, conditions, exclusions, and limitations of the member's benefit documents (for example, evidence of coverage, certificate of coverage, policy, or contract of insurance).
The policy is intended as a clinical guide to assist in determinations of medical necessity and to inform coverage decisions. It was developed by qualified health care professionals using current standards of practice and evidence. Explicit not medically necessary (NMN) conditions and specific exclusions referenced by the policy are described in the full policy document; this summary is not a contract and does not guarantee payment.
Coding and Procedural References
| No codes listed |
Provider Actions and Prior Authorization
Prior Authorization Required
Prior authorization is required before scheduling services covered by this clinical policy. Verify member eligibility and obtain authorization through the Health Plan's prior authorization portal or by contacting Provider Services. Claims submitted without required prior authorization may be denied.
- Check the member's benefit plan and eligibility prior to service.
- Obtain and document prior authorization number on the claim.
Provider Responsibility
This clinical policy is a guide to medical necessity and does not replace provider judgment. Providers remain responsible for delivering appropriate care and for documentation in the medical record to support the services billed.
- Providers must exercise independent professional judgment when treating members.
- Maintain complete medical records to support the medical necessity of services provided.
Coverage Decision Reminder
Coverage is subject to the terms, conditions, exclusions and limitations of the member's plan. Even if services meet clinical criteria, benefits may be denied if contractual or benefit requirements are not met.
- Reference the member's evidence of coverage, certificate of coverage, or contract for benefit limitations.
- Service authorization does not guarantee payment if performed outside benefit limits or network requirements.
Administrative Procedures Reminder
Follow all applicable Health Plan administrative policies and procedures; this clinical policy does not supersede contract terms or administrative rules. Check for state Medicaid provisions that may take precedence where applicable.
- Administrative requirements (billing, timely filing, network participation) remain in force.
- For Medicaid members, state Medicaid provisions override conflicting clinical policy statements.
Background and Evidence Review
References, evidence-based guideline sources, peer-reviewed literature, and input from practicing clinicians were reviewed in developing and updating the policy. The clinical policy reflects consideration of generally accepted standards of medical practice, government and professional society guidance, and published evidence to support the coverage criteria.
Definitions and Clinical References
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