CurrentCareSourcePolicy N/A

Breast Reduction Surgery (Reduction Mammoplasty) and Gynecomastia Surgery - Arkansas PASSE

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Defines medical necessity, coverage criteria, exclusions, and evaluation tools for breast reduction and gynecomastia surgery for CareSource members in Arkansas (AR PASSE); affects providers seeking authorization and payers adjudicating claims.

Policy Summary

PayerCareSource

PolicyBreast Reduction Surgery (Reduction Mammoplasty) and Gynecomastia Surgery

Policy CodePolicy N/A

Change TypeConservative therapy requirement addedgynecomastia criteria revisedexclusions clarified

Effective DateMay 1, 2026

Last ReviewMar 12, 2026

Next Review DateN/A

Key ActionObtain prior authorization with documentation of age/growth status, ≥3 months conservative therapy, functional symptoms, and Schnur Sliding Scale calculation.

SourceLink

POLICY UPDATE CHANGES

Added conservative management requirement to preoperative criteria (section D.I.C).

Revised gynecomastia criteria for duration and grade thresholds.

Clarified exclusions for cosmetic indications and liposuction.

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CurrentCareSourcePolicy N/A

Breast Reduction Surgery (Reduction Mammoplasty) and Gynecomastia Surgery - Arkansas PASSE

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Sign up for all CareSource policy alerts

Know when CareSource releases new policies or updates existing guidance.

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Policy Summary

PayerCareSource

PolicyBreast Reduction Surgery (Reduction Mammoplasty) and Gynecomastia Surgery

Policy CodePolicy N/A

Change TypeConservative therapy requirement addedgynecomastia criteria revisedexclusions clarified

Effective DateMay 1, 2026

Last ReviewMar 12, 2026

Next Review DateN/A

Key ActionObtain prior authorization with documentation of age/growth status, ≥3 months conservative therapy, functional symptoms, and Schnur Sliding Scale calculation.

SourceLink

POLICY UPDATE CHANGES

Added conservative management requirement to preoperative criteria (section D.I.C).

Revised gynecomastia criteria for duration and grade thresholds.

Clarified exclusions for cosmetic indications and liposuction.

>=3 monthsConservative treatment duration (min)

22nd pctSchnur Sliding Scale threshold

18 yrsMinimum age (default)

Women 40-54Mammogram requirement

LiposuctionNot medically necessary

Coverage criteria and medical necessity

Breast reduction surgery for macromastia — Medically necessary

Covered when ALL of the following are met:

Macromastia medical necessity criteria: Member is 18 years or older, or under 18 years with evidence that breasts have finished growing for a minimum of one year (parental/guardian consent required if under 18).all

Symptomatic interference: Breast size interferes with activities of daily living as indicated by one or more of: arm numbness consistent with brachial plexus compression syndrome; cervical pain; chronic breast pain; headaches; nipple position greater than 21 cm below suprasternal notch; persistent intertrigo below breasts nonresponsive to conventional/medical management; restriction of physical activity; severe bra-strap grooving or ulceration of shoulder; shoulder pain; thoracic kyphosis; upper or lower back pain.

Conservative therapy prerequisite: Member has tried at least 3 months of appropriate conservative treatments (examples: special support bras including wide-strap options, NSAIDs, physical therapy).

Surgeon preoperative evaluation: Preoperative evaluation by the surgeon concludes that the amount of breast tissue to be removed (by mass or volume) will provide a reasonable expectation of symptomatic relief.

Breast cancer screening: No evidence of breast cancer per age-appropriate screening: physician physical exam within the last year if under 40; women 40–54 with a negative mammogram within the year prior to planned surgery; women 55 and older with negative mammograms every 2 years (or earlier/more frequently per family history guidance).

Tissue removal threshold: Planned tissue removal per breast should be evaluated using the Schnur Sliding Scale; recommended weight to be removed from each breast is above the 22nd percentile for the member's BSA (BSA calculated using the Mosteller formula).

Schnur Sliding Scale required to evaluate grams per breast relative to BSA.

Breast reduction surgery for gynecomastia — Medically necessary

Covered when ALL of the following are met:

Gynecomastia eligibility: Member is 18 years or older, or under 18 with evidence that breasts have finished growing for a minimum of one year (parental/guardian consent required if under 18).

Clinical confirmation: A physical exam by an appropriately credentialed provider confirms the presence of gynecomastia.

Duration and grade criteria: For pubertal (adolescent) males: gynecomastia present for more than 1 year after pathological causes ruled out AND grade II, III, or IV. For postpubertal males: gynecomastia present for more than 3 months after pathological causes ruled out AND grade III or IV.

Tissue composition and reversible causes: The tissue being removed must be glandular breast tissue and not due to obesity, normal adolescence, or reversible drug effects that can be discontinued.

Liposuction as a technique to reduce breast volume is explicitly excluded. Liposuction to perform breast reduction is considered not medically necessary, and procedures using liposuction for this purpose will be denied.

Breast reduction performed solely for cosmetic indications is not covered. Examples include procedures done for poor posture, pendulousness, breast asymmetry, fit of clothing, or changes in nipple–areola appearance. The policy designates breast reduction solely for cosmetic indications and liposuction-based breast reduction as not medically necessary.

Coding, scales, and thresholds

No explicit CPT/ICD codes listed in documentmixed

No codes listed

inv-06: Schnur Sliding Scale minimum tissue removal — tissue removed must be above 22nd percentile per BSA (Mosteller) - key facts

Schnur Sliding Scale minimumTissue removed from each breast must be above the 22nd percentile on the Schnur Sliding Scale based on member BSA (Mosteller).

BSA calculationBody surface area (BSA) in m^2 is calculated using the Mosteller formula (sqrt[height (in) × weight (lbs) / 3131]).

PurposeScale estimates grams per breast to determine if planned reduction is medically necessary versus cosmetic.

Reference tableAppendix A provides 22nd percentile gram thresholds by BSA ranges (e.g., BSA 1.350–1.374 → 199 g per breast).

inv-07: Age / growth threshold — Member ≥18 years or <18 with breasts finished growing ≥1 year - key facts

Age/growth requirement

Prior authorization, documentation, and denial conditions

Prior Authorization

Prior authorization required with full supporting documentation

Prior authorization is required. The request must document that the member meets age/growth criteria, has functional symptoms interfering with activities of daily living, has attempted ≥3 months of appropriate conservative therapy, includes the surgeon's preoperative evaluation estimating tissue removal, and provides a Schnur Sliding Scale calculation showing grams per breast above the 22nd percentile for the member's BSA.

Member is ≥18 years or <18 with evidence breasts finished growing ≥1 year (parental/guardian consent if <18).
Evidence of functional symptoms (see policy list) interfering with activities of daily living.
Documentation of ≥3 months of appropriate conservative treatments.
Surgeon preoperative evaluation estimating tissue mass/volume to be removed and expected symptomatic relief.
Schnur Sliding Scale calculation: grams per breast >22nd percentile for member BSA.

Step Therapy

Background and rationale

Reduction mammoplasty is performed to decrease breast weight and volume with the goal of relieving symptoms caused by macromastia such as persistent neck, shoulder, or back pain, bra-strap grooving, intertrigo, neuropathic symptoms, and activity limitations. Surgical planning should document that the anticipated amount of tissue removal is expected to reasonably relieve the member’s functional symptoms.

Definitions and assessment tools

inv-14: Macromastia / Symptomatic Breast Hypertrophy — definition and common symptoms

DefinitionMacromastia (Breast Hypertrophy): an increase in volume and weight of breast tissue relative to body habitus.

Symptomatic breast hypertrophySyndrome of persistent neck/shoulder pain, bra-strap grooving, chronic intertriginous rash under breasts, headaches, backache, and upper extremity neuropathies due to excess breast weight.

Clinical impactSymptoms must interfere with activities of daily living to meet medical necessity criteria for reduction mammaplasty.

inv-15: Gynecomastia and Gynecomastia Scale — enlargement of male breast tissue and ASPS-derived grading used for coverage thresholds

DefinitionGynecomastia: enlargement of the male breast secondary to proliferation of ductal, stromal, and/or fatty tissue.

Gynecomastia Scale (ASPS-derived)

Policy Summary

PayerCareSource

PolicyBreast Reduction Surgery (Reduction Mammoplasty) and Gynecomastia Surgery

Policy CodePolicy N/A

Change TypeConservative therapy requirement addedgynecomastia criteria revisedexclusions clarified

Effective DateMay 1, 2026

Last ReviewMar 12, 2026

Next Review DateN/A

Key ActionObtain prior authorization with documentation of age/growth status, ≥3 months conservative therapy, functional symptoms, and Schnur Sliding Scale calculation.

SourceLink

On This Page

Underlying conditions considered: Gynecomastia should be attributed to or evaluated for underlying conditions when applicable (examples include androgen deficiency, chronic liver disease, Klinefelter syndrome, adrenal or testicular tumors, brain tumors, and other endocrine disorders).

List is not exhaustive.

Functional impairment and cancer rule-out: Gynecomastia causes functional impairment (eg, pain, chronic irritation) AND breast malignancy has been ruled out.

Tissue removal threshold: When applicable, planned tissue removal should be evaluated using the Schnur Sliding Scale; recommended weight to be removed from each breast is above the 22nd percentile for the member's BSA (BSA calculated using the Mosteller formula).

Member is ≥18 years, or if <18, breasts must have finished growing for a minimum of 1 year (parental/guardian consent required if <18).

DocumentationPreoperative documentation must include evidence breasts finished growing when member is under 18.

ApplicabilityRequirement applies to both macromastia (female) and gynecomastia (male) criteria as stated in policy.

Conservative therapy prerequisite: ≥3 months documented

At least 3 months of appropriate conservative treatments must be tried and documented prior to authorization; examples listed include special support bras, NSAIDs, and physical therapy.

Special support bras (including wide-strap options).
Nonsteroidal anti-inflammatory drugs (NSAIDs).
Physical therapy.

Documentation Required

Required clinical documentation for authorization

Clinical documentation submitted with the authorization must include the member's age or evidence breasts have finished growing (if under 18), signs/symptoms demonstrating interference with activities of daily living, details of the ≥3 months of conservative therapy tried, and the surgeon's preoperative evaluation estimating amount of tissue to be removed and expected symptomatic relief, including Schnur calculations.

Age or evidence breasts finished growing ≥1 year for members <18 (parental/guardian consent if <18).
One or more listed symptoms showing interference with activities (e.g., arm numbness, cervical pain, chronic breast pain, nipple position >21 cm below suprasternal notch, persistent intertrigo, restriction of physical activity, severe bra-strap grooving/ulceration, back pain, thoracic kyphosis).
Documentation of at least 3 months of conservative treatments tried and their outcomes.
Surgeon preoperative evaluation documenting planned tissue removal (mass or volume) and expectation of symptomatic relief.
Schnur Sliding Scale calculation showing grams per breast relative to member BSA.

Documentation Required

Document cancer screening per age: physical exam and mammogram requirements

Breast cancer must be ruled out per policy: a physician physical exam within the last year for members under 40, a negative mammogram within 1 year for women ages 40–54, and mammography per the stated intervals for older ages or with family-history adjustments.

Physical exam by a physician within the last year if under 40 years of age.
Women 40–54: negative mammogram within the year prior to planned surgery.
Women ≥55: negative mammograms every 2 years (or earlier with family history as specified).

Denial Risk

Denial triggers: cosmetic-only indications and liposuction reductions

Requests for procedures performed solely for cosmetic reasons or for breast reduction using liposuction will be denied as not medically necessary.

Liposuction to perform breast reduction is considered not medically necessary.
Breast reduction performed solely for cosmetic reasons (e.g., poor posture, pendulousness, breast asymmetry, fit of clothing, changes in nipple–areola appearance) will be denied.

Grade I: small enlargement with button of tissue at areola; Grade II: moderate enlargement beyond areola with indistinct edges; Grade III: moderate enlargement with distinct edges and skin redundancy; Grade IV: marked enlargement with skin redundancy and feminization.

Policy thresholdsCoverage criteria reference ASPS-derived grading to define grade thresholds (pubertal: Grade II–IV after >1 year; postpubertal: Grade III–IV after >3 months).

inv-16: Schnur Sliding Scale — tool to estimate grams to be removed relative to BSA; policy requires removal above 22nd percentile

Tool descriptionSchnur Sliding Scale estimates grams of tissue to be removed relative to member BSA to guide medical necessity determinations.

Policy requirementPolicy requires planned tissue removal per breast to exceed the 22nd percentile value on the Schnur Sliding Scale.

Calculation noteBSA used in the scale is calculated with the Mosteller formula as specified in policy.

Appendix detailAppendix A lists gram thresholds by BSA ranges (e.g., BSA 1.350–1.374 → 199 g at 22nd percentile).