Prior authorization required; include CPT 19318

Prior authorization is required per Capital Blue Cross program/product rules; include the reduction mammaplasty CPT procedure code 19318 on prior authorization submissions for surgical services governed by this policy.

• Procedure code listed: 19318

Use objective selection criteria with PA requests

Prior authorization decisions reference objective selection criteria — submit photographic evidence of breast size or shoulder grooving, documentation of planned/expected resection weight (commonly 500–600 g per breast or per Schnur Sliding Scale), and weight relative to ideal body weight when applicable.

• Photographs documenting breast size or shoulder grooving
• Planned/expected resection weight (commonly 500–600 g per breast) or Schnur Sliding Scale
• Requirement to be within 20% of ideal body weight (when used)

Include newly added ICD‑10 codes on authorization requests

Use the ICD‑10 diagnosis codes that were added to the policy when requesting authorization; include one or more listed diagnoses to support medical necessity.

• Examples of added codes: G54.0; G56.40–G56.43; M40.04; M53.83; M54.2; M54.6; M95.4; N64.4; Q83.8

Cite updated policy (effective 2025‑10‑01) and diagnoses

Reference the updated policy (effective 2025‑10‑01) and ensure authorization submissions include diagnoses consistent with the policy’s newly added ICD‑10 codes and updated Background/Policy Guidelines.

• Policy effective date: 2025-10-01
• Use updated Background/Rationale and Policy Guidelines when preparing PA documentation

Revise PAs to reflect 03/06/2025 removals and added ICD‑10 codes

After the 03/06/2025 Minor Review removed several indications and appended ICD‑10 codes, update prior authorization requests to reflect those removed indications and to use the policy’s added diagnosis codes.

• Removed indications include: breast pain; thoracic kyphosis; shoulder grooving; brachial plexus compression syndrome; congenital breast deformity
• Added ICD‑10 codes must be used where applicable

Include updated diagnosis codes on PA submissions

When submitting prior authorization, cite the appropriate ICD‑10 diagnosis codes added to the policy to support the indication for surgery.

• Required codes to reference include (as applicable): G54.0; G56.40; G56.41; G56.42; G56.43; M40.04; M53.83; M54.2; M54.6; M95.4; N64.4; Q83.8

Confirm indications and ICD‑10 codes before PA

Verify current medically necessary indications and the policy’s ICD‑10 code list before submitting prior authorization because recent revisions may affect coverage determinations.

• Confirm that removed indications are not being used as the sole justification for surgery
• Confirm which ICD‑10 codes apply to the member’s condition prior to PA submission

Ensure PA reflects updated indications (post‑03/06/2025)

Prior authorization determinations must follow the updated medically necessary indications after the 03/06/2025 removals; do not rely on indications that were removed when requesting authorization.

• Removed indications are not listed as medically necessary after 03/06/2025
• PA requests relying solely on removed indications may not meet criteria

Follow existing PA process but use updated references

Existing prior authorization processes remain operative, but providers must reference the updated policy language, added ICD‑10 codes, and Policy Guidelines when preparing submissions.

• Follow insurer’s standard PA submission requirements
• Include updated policy references and diagnosis codes

Add listed ICD‑10 codes to PA and documentation as applicable

The policy added multiple ICD‑10 codes to its coding list (see policy); include those newly added codes in documentation and authorization where applicable.

• Added codes include: G54.0; G56.40–G56.43; M40.04; M53.83; M54.2; M54.6; M95.4; N64.4; Q83.8

Provide supporting documentation per updated Policy Guidelines

Submit supporting documentation consistent with updated Policy Guidelines — include symptom history, conservative therapy attempts, photographs, and resection weight documentation as required by the revised guidance.

• Document minimum 6‑week symptom duration and failure of conservative therapy
• Provide photographs and planned/expected resection weight (commonly ≥500–600 g per breast or per Schnur)
• Follow the new Policy Guidelines in the full policy for additional documentation expectations

PA submission must comply with updated policy guidelines

Submit prior authorization consistent with the updated policy guidelines; prior authorization is required for surgical services governed by this medical policy.

• PA governed by Capital Blue Cross administrative processes for surgical services under this policy
• Follow updated Policy Guidelines when requesting authorization

Prior authorization required for surgical services under this policy

Prior authorization is required for reduction mammaplasty per Capital Blue Cross administrative rules; follow the insurer’s standard PA submission process for surgical services under this policy.

• PA requirement applies to programs/products administered by Capital Blue Cross

Document failed conservative therapy before PA

Require and document prior conservative therapy attempts (support bra, exercises, heat/cold, NSAIDs or muscle relaxants) and their failure before seeking authorization for surgery.

• Conservative therapies must be attempted and documented
• Examples: appropriate support bra, exercises, heat/cold, NSAIDs, muscle relaxants

Required documentation: symptom duration, conservative therapy, photos, resection weight

Document minimum symptom duration (at least 6 weeks), failure of conservative therapy, photographic evidence (breast size/shoulder grooving), and planned/actual resection weight (commonly 500–600 g per breast or per Schnur Sliding Scale) to support medical necessity.

• Minimum documented symptom duration: 6 weeks
• Photographs documenting breast size or shoulder grooving
• Planned/expected or actual resection weight (commonly 500–600 g per breast; Schnur may be used)

Include photographs, resection weight, and causation evidence in documentation

Photographic documentation, resection weight (or Schnur Sliding Scale), and evidence that macromastia is the primary cause of symptoms should be included in the record and PA submission to meet selection criteria.

• Photographs documenting shoulder grooving or breast size
• Planned/expected resection weight or Schnur Sliding Scale calculation
• Evidence macromastia is primary cause of symptoms

Use added ICD‑10 codes in documentation and claims

Use the policy’s added ICD‑10 codes to support diagnosis coding on claims and authorization requests (examples include G54.0, G56.40–G56.43, M40.04, M53.83, M54.2, M54.6, M95.4, N64.4, Q83.8).

• Include one or more of the policy-listed ICD‑10 codes when applicable to the clinical presentation

Align documentation with new Policy Guidelines and Background/Rationale

Ensure documentation aligns with the Policy Guidelines added in the 03/06/2025 Minor Review and with the Background/Rationale updates when requesting authorization.

• Consult the Policy Guidelines section in the full policy for specific documentation expectations
• Align documentation with updated Background and Rationale

Denial risk if required documentation is missing

Requests lacking required documentation (minimum 6‑week symptom history, failed conservative therapy, photographs, or resection weight/Schnur evidence) may be denied as not meeting medical necessity.

• Denial trigger: insufficient symptom duration or lack of documented conservative therapy failure
• Denial trigger: absence of photographic evidence or resection weight documentation

Selection criteria (photos, weight, Schnur, BMI) can trigger denial

Plans may use objective selection criteria (photographs, minimum resection weight commonly 500–600 g per breast, Schnur Sliding Scale, or being within 20% of ideal body weight); failure to meet these criteria can trigger coverage denial.

• Common minimum resection weight cited: 500–600 g per breast
• Schnur Sliding Scale used when resection weight <500–600 g
• Some protocols require patient within 20% of ideal body weight

Denial risk if relying on removed indications

Claims or prior authorization requests based solely on indications that were removed from the medically necessary list (breast pain; thoracic kyphosis; shoulder grooving; brachial plexus compression syndrome; congenital breast deformity) may be denied.

• Removed indications (03/06/2025): breast pain; thoracic kyphosis; shoulder grooving; brachial plexus compression syndrome; congenital breast deformity
• Do not submit PA relying only on these removed indications

Increased denial risk when removed indications are used

Removal of specific indications from the medically necessary list increases the risk of denial when those indications are cited as the primary justification for surgery.

• Providers should not cite removed indications as sole justification
• Verify current medically necessary indications before scheduling surgery or submitting a PA

Requests citing removed indications risk denial after 03/06/2025

Claims or PA requests referencing previously listed indications removed in the 03/06/2025 minor review may not meet the policy’s medically necessary indications and could be denied.

• Removed indications were explicitly listed in the 03/06/2025 Minor Review
• Requests referencing those indications may be subject to denial

Risk of not‑medically‑necessary determination when removed indications are used

If a procedure is performed for an indication removed from the medically necessary list, the claim may be considered not medically necessary — verify covered indications prior to performing surgery.

• Removed indications are no longer listed as medically necessary per the Minor Review
• Confirm covered indications to avoid post‑service denials