Reduction mammaplasty for breast-related symptoms
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This policy governs medical necessity coverage for reduction mammaplasty to treat symptomatic macromastia and reconstruction of the unaffected breast for symmetry after mastectomy for members of Capital Blue Cross products to which the policy applies.
No material clinical or coverage changes in this revision.
Coverage Criteria for Reduction Mammaplasty
Medically necessary indications
Covered when ALL of the following are met:
Primary clinical indications
- Symptom options: Either minimum 6-week history of pain not responsive to conservative therapy OR recurrent/chronic intertrigo6 weeks
See policy statement for conservative therapy examples
Reconstructive symmetry indication from policy
Investigational / Not covered indications
Policy statement
Medically Necessary Indications (historical and guideline context)
Policy history and prior criteria indicate objective measures used by Plans to determine medical necessity; the policy historically required macromastia to be the primary cause of symptoms and used objective selection criteria.
Documented as a requirement in prior policy criteria
These items were part of the 06/06/2022 criteria; later revisions removed specific items from the active policy history
Any indication that does not meet the specified criteria in this policy is considered investigational and not covered. Examples include absence of a documented minimum 6-week history of shoulder, neck, or back pain related to macromastia that is not responsive to conservative therapy (support bra, exercises, heat/cold, NSAIDs or muscle relaxants), lack of documented recurrent or chronic intertrigo between the pendulous breast and chest wall, or other clinical presentations not described in the medically necessary criteria.
Policy history documents that the list of qualifying indications has changed over time. Previous versions included a broader set of symptom items (for example: chronic breast pain due to weight, thoracic kyphosis, shoulder grooving, brachial plexus compression syndrome, congenital breast deformity) that have subsequently been removed or revised in later updates.
These historical changes are reflected in the policy history entries and in the note that specific ICD-10 codes and named indications were removed in updates (for example actions recorded in 03/06/2025 and other administrative reviews).
The policy cautions against using resected tissue weight or the Schnur Sliding Scale as the sole determinant of medical necessity. The Schnur Sliding Scale classifies resected weight relative to body surface area, with weights below the 5th percentile often considered cosmetic and weights above the 22nd percentile more likely considered medically necessary; values between these cutpoints are intended to be evaluated on a case-by-case basis.
Some Plans historically have applied objective weight cutpoints such as a commonly cited minimum of 500–600 grams per breast, and may require the patient to be within 20% of ideal body weight when using weight-based criteria. The policy notes that these weight-based thresholds are derived from surgeon-reported retrospective classifications and are not directly tied to surgical outcomes, and therefore should not be relied on as the only criterion for coverage decisions.
The policy history specifically records removal of several previously listed conditions and associated diagnosis codes from the medically necessary indications. In the 03/06/2025 update the policy removed items such as breast pain, thoracic kyphosis, shoulder grooving, brachial plexus compression syndrome and congenital breast deformity from the indication list and also removed a set of ICD-10 codes referenced in earlier versions.
Administrative and consensus reviews documented elsewhere in the history also reference additions and removals of ICD-10 codes (see policy history entries) and indicate that the inventory of qualifying diagnoses has been narrowed or modified over time.
Procedural and Diagnosis Codes, Selection Thresholds
| 19318 | Reduction mammaplasty |
| L24.A0 | Irritant contact dermatitis due to friction or contact with body fluids, unspecified |
| L24.A9 | Irritant contact dermatitis due friction or contact with other specified body fluids |
| L30.4 | Erythema intertrigo |
| L98.44 | Non-pressure chronic ulcer of chest |
| L98.491 | Non-pressure chronic ulcer of skin of other sites limited to breakdown of skin |
| M25.511 | Pain in right shoulder |
| M25.512 | Pain in left shoulder |
| M25.519 | Pain in unspecified shoulder |
| M53.83 | Other specified dorsopathies, cervicothoracic region |
| M54.2 | Cervicalgia |
| L98.491 | Non-pressure chronic ulcer of skin of other sites limited to breakdown of skin. |
| M25.511 | Pain in right shoulder. |
| M25.512 | Pain in left shoulder. |
| M25.519 | Pain in unspecified shoulder. |
| M53.83 | Other specified dorsopathies, cervicothoracic region. |
| M54.2 | Cervicalgia. |
| M54.6 | Pain in thoracic spine. |
| M54.89 | Other dorsalgia. |
| M54.9 | Dorsalgia, unspecified. |
| N62 | Hypertrophy of breast. |
| G56.40 | |
| G56.41 | |
| G56.42 | |
| G56.43 | |
| M40.04 | |
| M53.83 | |
| M54.2 | |
| M54.6 | |
| M95.4 | |
| N64.4 |
Provider Requirements, Prior Authorization, and Documentation
Prior authorization required for CPT 19318
Procedure code 19318 (reduction mammaplasty) is listed as covered when medically necessary; prior authorization is required through standard Capital Blue Cross processes for applicable products when submitting requests for this service.
Submit documentation with prior authorization
Providers must submit prior authorization requests with supporting documentation per Plan requirements; policy history notes that Plans may require documentation (photographs, resection estimates, symptom duration) when processing authorizations.
- Submit photos documenting breast size or shoulder grooving when requested
- Include documentation of planned resected tissue weight and symptom duration
Conservative therapy must be attempted and documented
Document that conservative therapy was tried and that shoulder, neck, or back pain persisted despite measures such as an appropriate support bra, exercises, heat/cold, and NSAIDs or muscle relaxants before considering surgery.
- Record duration and types of conservative treatments attempted
- Confirm pain not responsive to those measures
No additional step therapy specified
This policy does not specify any step therapy protocol beyond the requirement to try conservative measures; no additional formal step therapy algorithm is defined in the document.
Provide required supporting documentation
Include objective supporting documentation with the authorization request when Plan criteria require it, such as photographs showing breast size or shoulder grooving and documentation of the estimated amount of tissue to be resected.
- Photographs documenting breast size or shoulder strap grooving
- Estimated grams of tissue planned for resection
Documentation examples to include with requests
Examples of acceptable documentation include clinical photographs demonstrating breast size or shoulder grooving and explicit documentation of the planned resection weight in grams when Plan-specific criteria (minimum resection or Schnur Sliding Scale) are applied.
- Preoperative photographs (frontal and lateral views)
- Planned resection weight in grams per breast
Denial triggers: missing medical-necessity documentation
Claims or authorizations lacking required elements may be denied — common denial triggers include absence of a documented ≥6-week history of symptoms not responsive to conservative therapy, lack of documentation that macromastia is the primary cause of symptoms, or missing objective supporting documentation.
- No documented 6-week symptom duration
- No evidence conservative therapy failed
- Missing photographs or resection estimates when required
Failure to meet Plan objective selection criteria may cause denial
Plans may apply objective selection criteria (for example, required photographs, minimum resected tissue weight commonly 500–600 g per breast, use of the Schnur Sliding Scale, or requirement to be within 20% of ideal body weight); failure to meet Plan-specific objective criteria can result in denial of coverage.
- Minimum resection commonly cited as 500–600 grams per breast
- Use of the Schnur Sliding Scale for borderline resection weights
- Requirement to be within 20% of ideal body weight
Background and Context
Macromastia, also termed gigantomastia, is a condition of breast hyperplasia or hypertrophy that can produce physical symptoms including shoulder, neck, or back pain and recurrent intertrigo beneath pendulous breasts. Reduction mammaplasty removes excess breast tissue to relieve these physical symptoms and, when applicable, to restore symmetry following mastectomy.
Definitions
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