CurrentCareSourcePolicy N/A

Breast Reduction Surgery (reduction mammaplasty) and Gynecomastia Surgery

Defines medical necessity criteria, preoperative evaluation, and Schnur Sliding Scale thresholds for breast reduction (macromastia) and gynecomastia for members under the Arkansas PASSE program. Applies to providers submitting requests for surgical coverage.

Policy Summary

PayerCareSource

PolicyBreast Reduction Surgery (reduction mammaplasty) and Gynecomastia Surgery

Policy CodePolicy N/A

Change TypeRevised (background, definitions, gynecomastia criteria, references)

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with documentation demonstrating all medical necessity criteria are met, including age/growth status, symptoms, planned grams per breast relative to the Schnur Sliding Scale, and cancer screening per age/family history.

SourceLink

POLICY UPDATE CHANGES

Updated background and definitions, added D.I.D.4., revised gynecomastia criteria, and updated references.

18+minimum member age

>=22ndSchnur percentile threshold

MostellerBSA method

Appendix ASchnur table

Covered

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Coverage and Medical Necessity Criteria

Initial therapy — reduction mammaplasty

Covered when ALL of the following are met:

Macromastia coverage criteria: A. 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 is required for members under age 18. B. Breast size interferes with activities of daily living as indicated by one or more of the following: arm numbness consistent with brachial plexus compression syndrome; cervical pain; chronic breast pain; headaches; nipple position greater than 21 cm below the suprasternal notch; persistent redness and erythema (intertrigo) below the breasts; restriction of physical activity; severe bra strap grooving or ulceration of the shoulder; shoulder pain; thoracic kyphosis; or upper or lower back pain. C. Preoperative evaluation by the surgeon concludes the amount of breast tissue to be removed (by mass or volume) will provide a reasonable expectation of symptomatic relief. D. No evidence of breast cancer per required screening: physical exam within the last year if under 40 years; women 40–54 with negative mammogram within one year; women ≥55 with negative mammograms every 2 years; earlier/more frequent screening for family history as specified. E. Schnur Sliding Scale: planned weight of tissue to be removed per breast is recommended to be above the 22nd percentile for the member's BSA (BSA calculated using the Mosteller formula).

All elements A–E must be documented; include BSA (Mosteller) and planned grams per breast relative to the Schnur Sliding Scale (Appendix A).

Initial therapy — gynecomastia surgery

Covered when ALL of the following are met:

Gynecomastia coverage criteria: A. 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 is required for members under age 18. B. Physical exam by an appropriately credentialed provider confirms gynecomastia and meets duration and grade requirements: 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. C. The tissue to be removed is glandular breast tissue and not due to obesity, adolescence, or reversible drug effects. D. The gynecomastia causes functional impairment (e.g., pain, chronic irritation) and the surgery is not solely cosmetic. E. Breast malignancy has been ruled out.

All elements A–E must be documented prior to approval.

Procedures performed solely for cosmetic reasons are excluded from coverage. This exclusion specifically includes gynecomastia that is related to obesity, adolescence, or reversible drug effects, where surgical treatment would be considered cosmetic rather than medically necessary.

Gynecomastia surgery is considered not medically necessary when the condition is cosmetic in nature or is due to reversible causes such as drug effects or obesity. Coverage is only considered when the medical necessity criteria are met (see gynecomastia coverage criteria), and surgery is not indicated for purely cosmetic concerns.

Coding and Schnur Sliding Scale

Covered CPT Codes, Not specified in documentmixed

No codes listed

Schnur Sliding Scale — Appendix A (selected rows)

BSA range 1.350–1.374 m2Minimum grams per breast = 199

BSA range 1.650–1.674 m2Minimum grams per breast = 324

BSA range 2.100–2.124 m2Minimum grams per breast = 750

BSA range ≥2.550 m2Minimum grams per breast = 1662

Policy thresholdPlanned tissue removal per breast recommended to be above the 22nd percentile on the Schnur Sliding Scale

Schnur Sliding Scale — definition and use

Definition

Prior Authorization, Documentation, and Denial Conditions

Prior Authorization

Prior Authorization Required

Prior authorization required with documentation demonstrating all medical necessity criteria are met.

Prior authorization is required prior to breast reduction or gynecomastia surgery.
Include clinical documentation showing ALL applicable medical necessity criteria (see Policy: age/growth, symptoms, Schnur scale/BSA calculations, preoperative cancer screening).

Note

Provider Actions

Provider action: Not specified.

Documentation Required

Required Documentation

Clinical Definitions and Grading Scales

Macromastia / Symptomatic Breast Hypertrophy

DefinitionIncrease in breast volume/weight relative to body habitus producing persistent neck/shoulder pain, bra strap grooving, intertriginous rash, headaches, backache, and neuropathies

Common symptomsHeaviness, chronic pain, tension in neck/shoulders/upper back, shoulder grooving or ulceration

Indications for reductionChronic pain, neuropathy, breast discomfort, physical impairment, or psychological symptoms affecting activities or self-esteem

Gynecomastia

DefinitionBenign proliferation/enlargement of male glandular breast tissue (ductal, stromal, and/or fatty tissue)

ClassificationGraded by the ASPS Gynecomastia Scale: Grade I (small, periareolar) through Grade IV (marked enlargement with skin redundancy)

Clinical Background and Rationale

Macromastia (symptomatic breast hypertrophy) can produce significant physical and psychological burdens including a sensation of heaviness, chronic neck and back pain, bra strap grooving or shoulder ulceration, intertriginous dermatitis, headaches, and functional limitations that impair activities of daily living. Reduction mammaplasty (breast reduction) aims to reduce breast weight and volume to relieve these symptoms; the procedure may remove substantial tissue depending on body habitus and is performed when clinical criteria demonstrate that symptoms are attributable to breast hypertrophy and are likely to improve with tissue reduction.

Policy Revision History

2025-06-01Effective dateLatest

Policy effective date set to 2025-06-01 following committee approval and revision of background, definitions, gynecomastia criteria, and references.

2025-03-12Committee approval

Revisions approved at committee including updated background and definitions, addition of D.I.D.4., revision of gynecomastia criteria, and updated references (noted as part of Annual review).

2024-02-28New policy / Committee approval