ModifiedCentenePolicy CP MP.51

Reduction Mammoplasty and Gynecomastia Surgery

Medical necessity criteria and coding implications for breast reduction (reduction mammoplasty) and surgical treatment of gynecomastia for Centene-affiliated health plans, including documentation requirements and referenced appendices.

Policy Summary

PayerCentene

PolicyReduction Mammoplasty and Gynecomastia Surgery

Policy CodePolicy CP MP.51

Change TypeCriteria revised to add Schnur-based medical director review, ASPS alignment for gynecomastia timing, and mammogram requirement for age ≥40 with symptoms/high-risk

Effective Date

Next Review Date

Key ActionObtain prior authorization with medical records including height/weight, documentation of conservative therapies attempted, resection-weight relative to the Schnur Sliding Scale, and mammogram results when age ≥40 with symptoms/high-risk.

SourceLink

POLICY UPDATE CHANGES

Criteria updated to include a medical director review when the weight of resected tissue falls below the 22nd percentile on the Schnur Sliding Scale.

Gynecomastia persistence timeframes aligned with ASPS guidance for adolescents and adults (adolescents: specific durations; adults: >3 months after ruling out causes or unsuccessful medical treatment).

For members/enrollees >= 40 years with symptoms or high-risk factors, a mammogram negative for cancer is required within one year of the planned reduction mammoplasty.

Terminology changed to refer to 'those with a male reproductive system' and 'those with a female reproductive system' throughout criteria and background.

Clarifying language added and several criteria adjusted including mammogram requirement for members/enrollees 40 years with symptoms or high-risk factors, and removal of adult testicular size attainment criterion.

Schnur Sliding ScaleSchnur reference

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Coverage Criteria

Reduction Mammoplasty - Medical Necessity

Covered when ALL of the following are met

Age/Development: Member/enrollee is ≥18 years of age OR, for adolescents, Tanner stage V and no breast growth equivalent to a change in cup size for at least six monthssee Appendix A for Tanner staging

DuBois and DuBois BSA calculator may be used if only height and weight are provided

Schnur minimum: Estimated amount of breast tissue to be removed meets the minimum weight requirement based on member/enrollee body surface area per the Schnur Sliding Scale (Appendix B)Schnur Sliding Scale per Appendix B; if planned resection weight falls below the 22nd percentile, medical director review is required

See Appendix B for gram thresholds by BSA

Symptoms affecting activities of daily living: Member/enrollee has at least two of the specified symptoms affecting activities of daily living (examples include pain in neck/shoulders/arm/upper back not explained by other causes, headaches associated with neck/upper back pain, paresthesia from brachial plexus compression, painful kyphosis documented by X-ray, bra-strap grooving with ulceration, intertrigo of the inframammary folds)≥2 symptoms

See policy for full symptom list and exclusions (e.g., symptoms attributable to other diagnoses)

Conservative treatment: Pain or functional impairment unresponsive to conservative treatment with physician documentation of at least two therapeutic measures attempted (e.g., NSAIDs, physical therapy/exercise, supportive devices/brassieres, chiropractic/OMT, medically supervised weight loss, orthopedic or spine evaluation)>=2 conservative measures attempted and documented

Conservative therapies must be documented in the medical record

Breast cancer screening for older members: For members/enrollees ≥40 years with symptoms of breast cancer or high-risk factors, a mammogram negative for cancer performed within one year of the planned reduction mammoplasty is requiredmammogram within 1 year when indicated

Applies when symptomatic or high-risk per criteria

Gigantomastia of Pregnancy - Indications for Surgery

Covered when ANY of the listed complications are present in gestational gigantomastia and delivery is not imminent

Complications warranting surgery in gestational gigantomastia: Member/enrollee has gigantomastia of pregnancy accompanied by any of the following: massive infection; significant hemorrhage; ulceration of breast tissue; tissue necrosis with slough; or intertriginous maceration or infection of the inframammary skin that is refractory to dermatologic measurespresence of any listed complication

Surgical approach indicated when conservative treatment is ineffective or complications are present and delivery is not imminent

Gynecomastia - Medical Necessity

Gynecomastia surgery is medically necessary when the following age-specific criteria are met

Adolescents (≤18 years): Gynecomastia persists more than one year after pathological causes are ruled out for unilateral or bilateral Grade II or III; persists more than six months for Grade IV; and there is distention/tightness and discomfort not responsive to medical managementtimeframes per grade (Appendix C)

Includes discontinuation of gynecomastia-inducing drugs/substances and evaluation for pathological causes

Adults (≥18 years): Glandular breast tissue is the primary cause; gynecomastia persists for more than three months after pathological causes are ruled out OR symptoms persist >3 months after unsuccessful medical treatment; and presence of pain/discomfort due to distention/tightness not responsive to medical management>3 months persistence or post-treatment failure

Medication/substance discontinuation and evaluation for pathological causes required prior to surgical consideration

Key updated medical necessity criteria (summary)

Policy criteria updated and clarified; items shown here are summary highlights present in this document portion.

Medical director review when resection < Schnur percentile: When the planned weight of tissue to be resected is less than the Schnur sliding scale percentile minimum, the case requires medical director review on a case-by-case basis.resection weight < Schnur percentile

Added to Criteria I.A.2.

Mammogram requirement for age 40: Members/enrollees 40 years of age with symptoms of breast cancer or high-risk factors must have a mammogram as part of the criteria (performed within one year of planned procedure)age ≥40 with symptoms or high-risk

Added to Criteria LA.4.c and d (now in IAA.c.i–iii)

Alignment with ASPS guidance for gynecomastia timing: Criteria updated to align with American Society of Plastic Surgeons guidance regarding duration that gynecomastia persists in adolescents and adults; persistence timing clarified

Procedures performed specifically for gender-affirming care are not covered under this policy. See the referenced Centene policy CP MP.95 for coverage criteria and guidance related to gender-affirming chest surgeries.

Background text in this document has been edited to remove ICD-10 codes; this segment does not list explicit diagnosis-code-based exclusions. Refer to the full policy text for any code-specific guidance or exclusions.

Cases that do not meet the policy's required symptom counts, documented conservative-therapy timeframes, or the Schnur Sliding Scale minimum resection weight will be considered not to meet medical necessity unless a medical director review determines otherwise. The policy operationalizes case-by-case review when the planned resection weight is below the Schnur percentile minimum.

This portion of the document does not contain an explicit list of services labeled "not medically necessary." For determinations where criteria are not met, including specifics about non-covered conditions, refer to the full policy text for the formal "not medically necessary" statements and rationale.

Coding and Reference Tables

Referenced CPT CodesCPT

19300	Mastectomy for gynecomastia
19318	Breast reduction

Schnur Sliding Scale — minimum tissue weight per breast (Appendix B)

Schnur Sliding Scale (Appendix B)Table of minimum estimated tissue weight per breast by body surface area (BSA); example values shown in Appendix B range from about 135 g up to ~441 g corresponding to increasing BSA entries.

Example BSA entriesAppendix B lists paired BSA and minimum grams per breast (examples shown: 1.35 -> 199 g; 1.40 -> 218 g; 1.45 -> 238 g; 1.50 -> 260 g).

Upper-range examplesAppendix B includes higher BSA values with corresponding minima (examples shown include 1.70 -> 338 g; 1.75 -> 370 g; 1.80 -> 404 g; 1.85 -> 441 g).

Source and adaptationValues adapted from the Schnur Sliding Scale body surface area and estimated minimum cutoff weight for breast tissue per breast, presented in Appendix B.

Schnur Sliding Scale — policy application and below-threshold review

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for reduction mammoplasty and gynecomastia procedures. Submit requests with complete clinical documentation as outlined below; referenced CPT codes (e.g., 19300, 19318) are subject to prior authorization review.

Prior authorization required before scheduling or performing reduction mammoplasty (CPT 19318) and mastectomy for gynecomastia (CPT 19300).
Include the member/enrollee's height and weight on the request to allow BSA and Schnur sliding scale calculations.

Prior Authorization

Medical Director Review for Below-Threshold Resection

If the planned resection weight falls below the Schnur Sliding Scale minimum (22nd percentile by BSA), the case requires medical director review and will be considered on a case-by-case basis. Failure to obtain this review when applicable may affect coverage determination.

Medical director review required when estimated resection weight is less than the percentile minimum per the Schnur Sliding Scale.
Provide explicit calculation of estimated resection weight relative to the Schnur percentile on the submission.

Background

Reduction mammoplasty is a surgical procedure to decrease breast weight, mass, and size with the goal of relieving functional symptoms. Typical symptoms addressed include neck and upper back pain, shoulder grooving or bra strap grooving causing ulceration, intertrigo (skin irritation beneath the breast), paresthesia related to brachial plexus compression, headaches attributable to neck/upper back strain, and other functional limitations that affect activities of daily living. The procedure may also be indicated in cases of gestational gigantomastia with severe complications when conservative measures fail.

Definitions

Reduction mammoplasty — definition

DefinitionReduction mammoplasty is the surgical reduction of breast weight, mass, and size in those with a female reproductive system.

PurposePerformed to reduce breast volume and relieve related symptoms such as neck/upper back pain, bra-strap grooving, intertrigo, or functional limitations (background context in policy).

Gender-affirming noteBreast surgeries for gender affirmation are addressed in a separate policy (CP MP.95).

Gynecomastia surgery — definition

DefinitionGynecomastia surgery is the surgical correction of over-developed or enlarged breasts in those with a male reproductive system.

Clinical contextPhysiologic gynecomastia often resolves; surgical management is for persistent or symptomatic cases as defined in policy criteria.

Policy Summary

PayerCentene

PolicyReduction Mammoplasty and Gynecomastia Surgery

Policy CodePolicy CP MP.51

Change TypeCriteria revised to add Schnur-based medical director review, ASPS alignment for gynecomastia timing, and mammogram requirement for age ≥40 with symptoms/high-risk

Effective Date

Next Review Date

SourceLink

On This Page

Documentation Required

Required Clinical Documentation

Requests must be accompanied by medical records that document the clinical indications and support medical necessity. Photographic documentation may be requested when needed to corroborate written findings.

Include height and weight (for BSA/Schnur calculations).
Document symptoms affecting activities of daily living and physician evaluation findings.
If member/enrollee is ≥40 years with breast symptoms or high-risk factors, include a mammogram performed within one year of the planned procedure; if ≥40 with no symptoms and no high-risk factors, include a negative mammogram within one year as applicable.

Documentation Required

Conservative Therapy Documentation

Provide documentation of conservative therapy attempts showing that symptoms are refractory to nonoperative management prior to approval for reduction mammoplasty.

Document at least two conservative measures tried, such as: NSAIDs/analgesics; physical therapy/exercise when skeletal pathology is present; supportive devices (proper bra support, wide straps); chiropractic/osteopathic manipulation; medically supervised weight loss; orthopedic or spine evaluation when appropriate.
Record duration and response to each conservative therapy in the medical record.

Denial Risk

Insufficient Documentation / Denial Risk

Incomplete or missing documentation may render a request incomplete and delay processing or lead to denial. Ensure all required elements are provided at time of submission.

Requests lacking height/weight, conservative therapy documentation, estimated resection weight relative to Schnur scale, or required mammography (when applicable) may be considered incomplete.
If photographic documentation was requested and not provided, the request may be delayed.