CurrentBlue Cross Blue Shield - North DakotaPolicy 60

Reduction Mammaplasty

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This policy governs coverage of surgical breast reduction, including medical necessity criteria, documentation requirements, Schnur Sliding Scale tissue-removal thresholds, and exclusions for cosmetic, gynecomastia-related, and liposuction-only procedures. It applies to providers seeking coverage for reduction mammaplasty under applicable member contracts.

Policy Summary

PayerBlue Cross Blue Shield - North Dakota

PolicyReduction Mammaplasty

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNovember 1, 2026

Last ReviewJun 1, 2026

Next Review DateJuly 1, 2027

Key ActionSubmit the expected breast tissue removal amount, laterality, patient height and weight, and supporting clinical records.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

199 gMinimum tissue removal below 1.350 m² BSA

12 moQualifying pain duration

3 moConservative therapy duration

4Qualifying indication categories

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CurrentBlue Cross Blue Shield - North DakotaPolicy 60

Reduction Mammaplasty

Customize your policy alerts

Sign up for Blue Cross Blue Shield - North Dakota Policy 60 alerts

Get alerted when Policy 60 changes without checking for updates manually.

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Policy Summary

PayerBlue Cross Blue Shield - North Dakota

PolicyReduction Mammaplasty

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNovember 1, 2026

Last ReviewJun 1, 2026

Next Review DateJuly 1, 2027

Key ActionSubmit the expected breast tissue removal amount, laterality, patient height and weight, and supporting clinical records.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

199 gMinimum tissue removal below 1.350 m² BSA

12 moQualifying pain duration

3 moConservative therapy duration

4Qualifying indication categories

Liposuction aloneInvestigational technique

2Procedure codes listed

Medical Necessity and Exclusions

Medically necessary reduction mammaplasty

Reduction mammaplasty may be considered medically necessary when at least one of the following pathways is met:

Qualifying coverage pathway

Preparatory first-stage procedure
- The procedure precedes a nipple-sparing mastectomy, and the amount of breast tissue removed from each breast meets the minimum grams-per-breast requirement for the patient's body surface area under the Schnur Sliding Scale.Schnur Sliding Scale minimum per breast
Standard reduction mammaplasty criteria
- Age requirement
  - The individual is age 18 years or older.Age 18+
  - Younger adolescent exception
    The individual is at least 16 years old, breast size has been stable for at least 12 months, and the provider has documented why intervention before age 18 is medically necessary.Age 16+ and breast-size stability for at least 12 months
- The amount of breast tissue removed from each breast, excluding fat removed by liposuction, meets the minimum grams-per-breast requirement for the patient's body surface area under the Schnur Sliding Scale. In cases of asymmetry where only one breast meets the individual threshold, the combined tissue removed from both breasts must equal at least twice the Schnur minimum for the patient's body surface area.Schnur Sliding Scale minimum; asymmetric cases require combined tissue weight at least twice the minimum
  The health plan may review medical records to confirm the amount of breast tissue removed.
- Qualifying clinical indication
  - Pain is present in the upper back, neck, shoulders, and/or arms for at least 12 months; a clinical evaluation determined that the pain is not secondary to another identifiable condition; and the pain is not relieved by at least three months of conservative therapy, such as an appropriate wide-strap support bra, exercises, heat or cold treatments, and appropriate nonsteroidal anti-inflammatory agents or muscle relaxants.Pain for at least 12 months; conservative therapy for at least 3 months
    Pain documentation must be supplied by the referring provider rather than the surgeon.
  - Intertrigo between the pendulous breasts and chest wall persists despite at least three months of conservative dermatologic treatment, such as reducing friction, heat, and maceration by keeping the skin cool and dry and using antimycotic agents when appropriate.Conservative dermatologic treatment for at least 3 months
  - Kyphosis is documented by x-ray.Radiographic documentation required

Medically necessary reduction mammaplasty for female breast hypertrophy or macromastia

Reduction mammaplasty for female breast hypertrophy or macromastia may be considered medically necessary when the applicable policy criteria are met.

Reduction mammaplasty may be considered medically necessary for female breast hypertrophy or macromastia when the applicable policy criteria are met.

This policy does not apply to reconstruction after a prior partial or complete mastectomy when the Women’s Health & Cancer Rights Act applies. Such services should be evaluated under the applicable reconstructive breast surgery policy.

This policy does not address treatment of gender dysphoria. The applicable transgender services medical policy may apply.

Reduction mammaplasty involving partial removal of glandular tissue for gynecomastia is not medically necessary. The stated standard of care is removal of most or all glandular tissue.

Reduction mammaplasty by liposuction alone is considered investigational because there is insufficient research to show that liposuction mammaplasty improves health outcomes more than traditional mammaplasty techniques.

Reduction mammaplasty is not medically necessary when the applicable medical-necessity criteria are not met.

Reduction mammaplasty performed for gynecomastia is considered not medically necessary.

The use of liposuction as an additional procedure with breast reduction surgery is considered not medically necessary.

Reduction mammaplasty for female breast hypertrophy or macromastia is considered not medically necessary when the applicable policy criteria are not met.

Reduction mammaplasty involving partial removal for treatment of gynecomastia is considered not medically necessary; the current standard of care is removal of most or all glandular tissue.

Codes, Formula, and Tissue-Removal Thresholds

CPT HCPCSCPT

15877	Suction assisted lipectomy; trunk
19318	Breast reduction

Included component; not separately allowableCPTNot Covered

19350

Nipple/areola reconstruction

Mosteller Body Surface Area Formula

FormulaBody surface area (m²) = ([height (cm) × weight (kg)] / 3600)½

Height inputHeight is entered in centimeters (cm).

Weight inputWeight is entered in kilograms (kg).

Schnur Sliding Scale: Lower Body Surface Area

BSA below 1.350 m²Minimum breast tissue removal: 199 g per breast.

BSA 1.350–1.374 m²Minimum breast tissue removal: 199 g per breast.

BSA 1.375–1.399 m²

Documentation and Submission Requirements

Documentation Required

Submit Tissue Amounts and Measurements

Submit the total expected breast tissue removal, specifying the amount for the left and right sides and whether the procedure is bilateral. Include the patient’s height and weight.

Expected tissue removal amount by side: left/right or bilateral
Patient height and weight

Documentation Required

Submit Complete Clinical Records

Submit complete clinical records supporting the request. Missing information may affect the review and coverage determination.

Chart notes and medical records, including primary care records
History and physical examinations
Physical therapy notes
Radiologic examinations
Dermatology treatment notes

Clinical Context

Female breast hypertrophy, or macromastia, involves abnormally large breasts that may adversely affect the shoulders, neck, and trunk. Persistent symptoms such as shoulder, neck, or back pain, shoulder grooving, or intertrigo distinguish symptomatic macromastia from breasts that are large but otherwise normal. Reduction mammaplasty may alleviate these signs and symptoms by removing excess breast tissue.

Key Terms

Reduction Mammaplasty

ProcedureReduction mammaplasty is the surgical excision of a substantial portion of the breast.

Tissue removedThe excision includes the skin and underlying glandular tissue.

Intended resultTissue is removed until a clinically normal size is obtained.

Female Breast Hypertrophy (Macromastia)

ConditionFemale breast hypertrophy, or macromastia, is the development of abnormally large breasts in the female.

Affected structuresExcessive breast weight can adversely affect the supporting structures of the shoulders, neck, and trunk.

Clinical manifestations

Policy Summary

PayerBlue Cross Blue Shield - North Dakota

PolicyReduction Mammaplasty

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNovember 1, 2026

Last ReviewJun 1, 2026

Next Review DateJuly 1, 2027

Key ActionSubmit the expected breast tissue removal amount, laterality, patient height and weight, and supporting clinical records.

SourceLink

On This Page

Ulnar paresthesia is not relieved by at least three months of conservative therapy, such as an appropriate wide-strap support bra, range-of-motion exercises, physical therapy, and appropriate nonsteroidal anti-inflammatory agents or muscle relaxants.Conservative therapy for at least 3 months

Minimum breast tissue removal: 208 g per breast.

BSA 1.400–1.424 m²Minimum breast tissue removal: 218 g per breast.

BSA 1.425–1.449 m²Minimum breast tissue removal: 227 g per breast.

BSA 1.450–1.474 m²Minimum breast tissue removal: 238 g per breast.

Schnur Sliding Scale: BSA 1.500–2.099 m²

BSA 1.500–1.624 m²1.500–1.524: 260 g; 1.525–1.549: 272 g; 1.550–1.574: 284 g; 1.575–1.599: 297 g; 1.600–1.624: 310 g.

BSA 1.625–1.749 m²1.625–1.649: 324 g; 1.650–1.674: 338 g; 1.675–1.699: 354 g; 1.700–1.724: 370 g; 1.725–1.749: 386 g.

BSA 1.750–1.874 m²1.750–1.774: 404 g; 1.775–1.799: 422 g; 1.800–1.824: 441 g; 1.825–1.849: 461 g; 1.850–1.874: 482 g.

BSA 1.875–1.999 m²1.875–1.899: 504 g; 1.900–1.924: 527 g; 1.925–1.949: 550 g; 1.950–1.974: 575 g; 1.975–1.999: 601 g.

BSA 2.000–2.099 m²2.000–2.024: 628 g; 2.025–2.049: 657 g; 2.050–2.074: 687 g; 2.075–2.099: 717 g.

Schnur Sliding Scale: BSA 2.125 m² and Above

BSA 2.125–2.224 m²2.125–2.149: 784 g; 2.150–2.174: 819 g; 2.175–2.199: 856 g; 2.200–2.224: 895 g.

BSA 2.225–2.424 m²2.225–2.249: 935 g; 2.250–2.274: 978 g; 2.275–2.299: 1022 g; 2.300–2.324: 1068 g; 2.325–2.349: 1117 g; 2.350–2.374: 1167 g; 2.375–2.399: 1219 g; 2.400–2.424: 1275 g.

BSA 2.425–2.524 m²2.425–2.449: 1333 g; 2.450–2.474: 1393 g; 2.475–2.499: 1455 g; 2.500–2.524: 1522 g.

BSA 2.525–2.549 m²Minimum breast tissue removal: 1590 g.

BSA 2.550 m² or greaterMinimum breast tissue removal: 1662 g.

Other relevant clinical notes and supporting records

Documentation Required

Document Qualifying Pain

Provide documentation from the primary care or referring provider of long-standing pain in the upper back, neck, shoulders, and/or arms. Records should include evaluation for other possible pain sources and treatment with at least three months of conservative therapy.

Document the location and long-standing nature of the pain
Include evaluation for other conditions that may be causing the pain
Include detailed treatment records for at least three months of conservative therapy

Documentation Required

Document Persistent Intertrigo

Document intertrigo and show that it persisted despite at least three months of conservative treatment.

Include detailed records of the conservative treatment provided and its outcome

Documentation Required

Submit Kyphosis Imaging

Submit an x-ray documenting kyphosis.

Documentation Required

Document Ulnar Paresthesia

Document ulnar paresthesia that persisted despite at least three months of conservative therapy, including the specific treatment provided and the outcome.

Include chart notes detailing the specific treatment
Document treatment duration and outcome

Documentation Required

Use a Qualified Referring Provider

Pain-related documentation must come from a designated healthcare professional licensed to perform a complete medical examination.

Acceptable providers include a medical doctor, osteopathic physician, or nurse practitioner
Chiropractors, physical therapists, and massage therapists do not meet this referring-provider requirement

Documentation Required

Document Symptoms and Functional Impact

Document the symptoms associated with breast hypertrophy or macromastia and their effect on function. Records may include movement-related neck, back, or breast pain and difficulty performing daily activities.

Pain in the neck, back, or breasts related to movement
Difficulty with activities such as grocery shopping, banking, transportation, meal preparation, feeding, or showering
Secondary complications or infections, including intertrigo, chronic rash, cervicalgia, dorsalgia, or kyphosis
Photographs showing breast appearance, possible shoulder grooves, or kyphosis may be included

Denial Risk

Criteria Not Met

Reduction mammaplasty for macromastia is not medically necessary when the policy’s medical-necessity criteria are not met.

Denial Risk

Gynecomastia Indication

Reduction mammaplasty performed for gynecomastia is not medically necessary.

Denial Risk

Additional Liposuction

Liposuction used as an additional procedure with breast reduction surgery is not medically necessary.

Denial Risk

Liposuction-Only Reduction

Liposuction as the sole procedure for breast reduction is investigational.

Note

Prior Mastectomy

This policy does not apply when the patient has had a prior mastectomy for which the Women’s Health & Cancer Rights Act applies. Refer to the applicable reconstruction policy.

See Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants, Surgery Policy No. 40
Refer to Surgery Policy No. 40 for reconstruction after partial or complete mastectomy

Note

Gender Dysphoria

This policy does not address treatment of gender dysphoria. Refer to the applicable transgender services policy.

See Transgender Services medical policy, Medicine Policy No. 153

Denial Risk

Macromastia Criteria Not Met

Reduction mammaplasty for female breast hypertrophy or macromastia is not medically necessary when the policy criteria are unmet.

Denial Risk

Gynecomastia Procedure Does Not Match Standard of Care

Partial removal of glandular tissue for gynecomastia is not medically necessary because it does not match the standard of care, which is removal of most or all glandular tissue.

Denial Risk

Liposuction-Only Breast Reduction

Reduction mammaplasty by liposuction alone is investigational because there is insufficient research to demonstrate improved health outcomes compared with traditional mammaplasty techniques.

Persistent symptoms may include shoulder, neck, or back pain, shoulder grooving, or intertrigo.

Designated Referring Provider

Eligible providersA medical doctor, osteopathic physician, or nurse practitioner may serve as the designated referring provider.

License requirementThe provider must be licensed to perform a complete medical examination.

Excluded providersChiropractors, physical therapists, and massage therapists are not included.

Female Breast Hypertrophy / Macromastia

DefinitionFemale breast hypertrophy, or macromastia, is the development of abnormally large breasts.

Medical effectsThe condition can cause medical problems.

Coverage contextReduction mammaplasty may be considered medically necessary when policy criteria are met; it is not medically necessary when the criteria are not met.

Gynecomastia

ConditionGynecomastia is benign enlargement of the male breast.

Primary tissue involvedThe enlargement is mainly due to excessive growth of glandular tissue.

Reduction procedure contextPartial removal for treatment of gynecomastia is considered not medically necessary; the current standard of care is removal of most or all glandular tissue.

Liposuction Mammaplasty

DefinitionLiposuction mammaplasty is reduction mammaplasty performed using liposuction alone.

Technique distinctionIt is performed instead of traditional mammaplasty techniques.

Policy statusReduction mammaplasty by liposuction alone is considered investigational.