Currentcare_continuumPolicy n00229

Reduction Mammoplasty Medical

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Defines medical necessity criteria, documentation requirements, and exclusions for coverage of reduction mammoplasty for Network Health/Network Health Insurance Corporation/Network Health Administrative Services members, including application to Medicare Advantage when CMS determinations are absent.

Policy Summary

Payercare_continuum

PolicyReduction Mammoplasty Medical

Policy CodePolicy n00229

Change TypeNo material changes

Effective DateJul 27, 2000

Last ReviewDec 18, 2025

Next Review DateDec 12, 202650d

Key ActionObtain prior authorization and submit documentation demonstrating medical necessity including Schnur Sliding Scale calculations and evidence of ≥3 months conservative therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsbreast size stability required prior to approval

≥3 monthsminimum prior conservative therapy duration

D cup+bra size threshold referenced in criteria

Schnurexcess tissue estimation method required

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Currentcare_continuumPolicy n00229

Reduction Mammoplasty Medical

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Policy Summary

Payercare_continuum

PolicyReduction Mammoplasty Medical

Policy CodePolicy n00229

Change TypeNo material changes

Effective DateJul 27, 2000

Last ReviewDec 18, 2025

Next Review DateDec 12, 202650d

Key ActionObtain prior authorization and submit documentation demonstrating medical necessity including Schnur Sliding Scale calculations and evidence of ≥3 months conservative therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsbreast size stability required prior to approval

≥3 monthsminimum prior conservative therapy duration

D cup+bra size threshold referenced in criteria

Schnurexcess tissue estimation method required

Coverage Criteria for Reduction Mammoplasty

Medically necessary reduction mammoplasty

Covered when ALL of the following are met:

Overall: All criteria below must be met

Anatomic/Size: Breast macromastia, hypertrophy, or gigantism on physical exam with bra size D cup or larger; AND estimated excess breast tissue to be removed meets Schnur Sliding Scale minimumsD cup or larger; Schnur Sliding Scale

See Appendix A or B for Schnur Sliding Scale values

Symptom or physical finding: Either: (1) pain in upper back, neck and/or shoulders causing interference with activities of daily living and not responding to conservative treatment for at least 3 months, and pain not primarily due to another diagnosis (e.g., arthritis); OR (2) ulceration of shoulder skin; OR (3) shoulder grooving not responding to conservative treatment; OR (4) intertrigo between the breast and chest wall>= 3 months conservative therapy for pain

Conservative therapy defined below

Cancer screening: No evidence of breast cancer: normal mammogram for adults age >= 40 OR normal breast exam for individuals under 40age-based

Stability: Breast size has been stable for at least 6 months6 months

Procedure will not be approved until this is met

Reduction mammoplasty is not a covered benefit when the clinical indications and documentation requirements listed in this policy are not all met. Specifically, if the required documentation, conservative therapy trial, Schnur Sliding Scale minimum tissue estimates, or other medical necessity criteria are absent or not satisfied, the procedure will be considered cosmetic or as surgical treatment of obesity and will be excluded from coverage.

Cosmetic procedures performed solely to reshape the breasts to improve appearance are not a covered benefit under this policy.

Coding and Measurement Guidance

CPT Codes referencedCPT

19318	Reduction mammaplasty.
19324	Mammaplasty, augmentation; without prosthetic implant.
19325	Mammaplasty, augmentation; with prosthetic implant.

CPT

No codes listed

Schnur Sliding Scale / Minimum grams to remove

What to useMinimum grams per breast as specified by the Schnur Sliding Scale charts (Appendix A/B). Round upward if between listed increments; removal of more tissue is permissible.

Location in policyAppendix A (Height and Weight) and Appendix B (BSA) contain the Schnur Sliding Scale charts used to determine minimum grams to remove.

Rounding ruleIf the calculated weight falls between listed increments on the Schnur chart, round upward to the next increment.

Permissible deviationRemoval of more tissue than the Schnur minimum is permissible when clinically indicated.

Provider Requirements and Administrative Actions

Prior Authorization

Prior authorization required — submit documentation demonstrating medical necessity

Prior authorization is required per plan coverage. Submit the prior authorization request and include the documentation described in this policy demonstrating medical necessity, including the Schnur Sliding Scale estimate and evidence of a conservative therapy trial.

Include CPT code(s): 19318, 19324, 19325 as applicable.
Attach Schnur Sliding Scale calculation showing minimum grams planned for removal.
Provide records showing conservative therapy tried and failed (see documentation requirements).

Step Therapy

Conservative therapy trial required for ≥3 months

A course of conservative therapy must have been tried for at least three (3) months before approval; this includes use of an appropriate support bra, exercises, heat/cold treatment, and appropriate NSAIDs/muscle relaxants.

Background

Reduction mammoplasty is surgical reconstruction of the breast intended to reduce breast size and weight. This policy references the use of the Schnur Sliding Scale (Appendix A/B) to estimate the minimum grams of tissue planned for removal and requires that breast size be stable for at least 6 months and that a course of conservative therapy has been tried for at least 3 months prior to approval. The policy also requires appropriate cancer screening (normal mammogram if age ≥40, or normal breast exam if <40) and submission of pertinent medical records documenting height and weight, anticipated tissue removal, and symptom impact.

Definitions

Reduction mammoplasty definition

DefinitionReduction mammoplasty is the surgical reconstruction of the breast to reduce size and weight of mammary tissue.

Age considerationShould be delayed until a girl's breast tissue is fully matured, usually at 16–17 years of age.

Medical indication summaryIndicated for breast macromastia/hypertrophy/gigantism with bra size D cup or larger when criteria (including Schnur minimums and symptom criteria) are met.

Conservative therapy definition

Core componentsSupport bra, exercises, heat/cold treatment, and appropriate non-steroidal anti-inflammatory agents/muscle relaxants tried for at least 3 months.

Prerequisite for pain criteriaPain in upper back, neck, and/or shoulders must be nonresponsive to conservative therapy for ≥3 months before surgery is considered.