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    v1.0.28
    OpenPayerPolicy UpdatesPlastic/Reconstructive Surgerycare_continuum Reduction Mammoplasty Coverage Upda…
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    Currentcare_continuumPolicy n00229

    Reduction Mammoplasty (Breast Reduction) — Coverage Criteria

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    Clinical guidance for Utilization Management Coordinators and reviewers on medical necessity determinations for reduction mammoplasty (breast reduction) surgeries for Network Health Plan members.

    Policy Summary
    Payercare_continuum
    PolicyReduction Mammoplasty (Breast Reduction) — Coverage Criteria
    Policy CodePolicy n00229
    Change TypeAnnual review — references/grammar/CPT verification
    Effective DateDec 18, 2025
    Last ReviewDec 18, 2025
    Next Review Date
    Key ActionSubmit prior authorization and clinical documentation demonstrating that planned tissue removal is reasonably expected to relieve symptoms per CMS LCD L35001 and MCG A-0274.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    AnnualReview cadence
    NoContent change
    DoneCPT verification
    UpdatedReferences

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Coverage Criteria

    Referenced medical necessity criteria

    Coverage determinations reference existing external criteria.

    Referenced criteria: Medical necessity is determined per CMS Local Coverage Determination (LCD) L35001 and MCG Ambulatory Care 29th Edition A-0274. These referenced criteria require that: (1) breast size interferes with activities of daily living; (2) a pre-operative surgeon evaluation concludes the amount of breast tissue planned for removal is reasonably expected to provide symptom relief; and (3) there is no evidence of breast cancer.see referenced documents

    Document does not specify numeric thresholds (e.g., grams to be removed) or minimum age; reviewers should apply the referenced LCD/MCG criteria.

    Coverage determinations reference external medical necessity criteria and exclude cases with evidence of breast cancer. Reviewers must apply the referenced CMS and MCG guidance — specifically CMS LCD L35001 and MCG Ambulatory Care 29th Edition A-0274 — which require that breast size interferes with activities of daily living, that a pre-operative surgeon evaluation concludes the planned tissue removal is reasonably expected to provide symptom relief, and that there is no evidence of breast cancer for the typical reduction mammoplasty indication.

    This review did not add any new not medically necessary statements. Existing utilization guidance remains unchanged, and prior determinations based on the referenced CMS LCD L35001 and MCG A-0274 criteria continue to apply; the document update consisted of reference and editorial updates and CPT code verification only.

    Provider Actions & Requirements

    Prior Authorization

    Prior authorization must follow CMS LCD L35001 and MCG A-0274

    Follow the plan's prior authorization process and make determinations using the referenced medical necessity criteria: CMS LCD L35001 Reduction Mammoplasty and MCG Ambulatory Care A-0274 Reduction Mammaplasty (Mammoplasty).

    Step Therapy

    No step therapy required

    This policy does not specify any step therapy requirements for reduction mammoplasty.

    Documentation Required

    Submit clinical documentation supporting reduction and expected symptom relief

    Background

    Background: Reduction mammoplasty is the surgical reconstruction of the breast to reduce size and weight of mammary tissues. MCG Ambulatory Care 29th Edition (A-0274) and CMS LCD L35001 provide the clinical indications used to determine medical necessity, focusing on interference with activities of daily living and a pre-operative surgeon assessment that planned tissue removal is reasonably expected to relieve symptoms; these references do not specify a minimum age or a numeric tissue-amount threshold.

    Definitions

    Reduction mammoplasty (definition)
    DefinitionReduction mammoplasty is the surgical reconstruction of the breast to reduce size and weight of mammary tissues.
    Clinical contextUsed when breast size/weight interferes with activities of daily living and planned tissue removal is expected to relieve symptoms (see referenced CMS LCD L35001 and MCG Ambulatory Care A-0274).
    Documentation requirementPre-operative surgeon evaluation must conclude the planned tissue removal is reasonably expected to provide symptom relief; documentation should align with referenced LCD/MCG criteria.
    Coverage stanceCovered with criteria — determinations reference external CMS and MCG medical necessity criteria; no new internal thresholds specified.
    Review frequencyPolicy scheduled for annual review.
    Policy Summary
    Payercare_continuum
    PolicyReduction Mammoplasty (Breast Reduction) — Coverage Criteria
    Policy CodePolicy n00229
    Change TypeAnnual review — references/grammar/CPT verification
    Effective DateDec 18, 2025
    Last ReviewDec 18, 2025
    Next Review Date
    Key ActionSubmit prior authorization and clinical documentation demonstrating that planned tissue removal is reasonably expected to relieve symptoms per CMS LCD L35001 and MCG A-0274.
    SourceLink
    On This Page
    Coverage CriteriaProvider Actions & RequirementsBackgroundDefinitions

    Provide clinical documentation that the procedure is a reduction mammoplasty intended to reduce the size and weight of mammary tissues and that a pre‑operative surgeon evaluation concludes the planned tissue removal is reasonably expected to relieve symptoms.

    • Documentation should align with the referenced criteria in CMS LCD L35001 and MCG Ambulatory Care A-0274.
    • Include surgeon pre‑op evaluation findings describing symptoms related to breast size and the expected benefit from the planned tissue removal.
    Denial Risk

    Risk of denial if documentation/medical necessity criteria not met

    Claims or prior authorization requests may be denied if required documentation or the referenced medical necessity criteria are not met.

    • Denial risk exists because no content changes were made and utilization determinations continue to rely on the referenced LCD/MCG criteria.
    • Ensure documentation shows no evidence of breast cancer per the referenced criteria to avoid exclusion.