CurrentCignaPolicy 0152

Breast Reduction

Cigna coverage policy governing breast reduction for symptomatic macromastia and breast reduction on the contralateral/non-diseased breast for symmetry after mastectomy or lumpectomy; applies to Cigna-administered health benefit plans and providers seeking coverage determinations.

Policy Summary

PayerCigna

PolicyBreast Reduction

Policy CodePolicy 0152

Change TypeAnnual review — addition

Effective Date11/15/2025

Next Review Date08/15/2026

Key ActionObtain and document prior authorization and preoperative photographs and supporting documentation to demonstrate medical necessity for breast reduction.

SourceLink

POLICY UPDATE CHANGES

Added policy statement for excision of redundant skin for correction of tissue protruding at the end of a breast reduction incision or scar.

No clinical policy statement changes during the annual review dated 8/15/2024.

2025-11-15policy effective date

19318primary procedure

Schnur >22%resection weight threshold

2medically necessary CPTs listed

cosmetic/not medically necessary CPTs

Coverage Criteria: When Reduction Mammaplasty Is Medically Necessary

Initial coverage criteria

Covered when ALL of the following are met

Age/Breast maturity: Individual is a woman at least 18 years of age, or has completed breast growth>=18 years or completed breast growth

See professional society guidance for adolescents when severe symptoms exist

Symptoms attributable to macromastia: Macromastia is causing at least ONE of the following that has been unresponsive to medical management: shoulder or upper back/neck pain and/or ulnar nerve palsy without another identified etiology; intertrigo, dermatitis, eczema, or hidradenitis at the inframammary foldAt least one symptom persists despite medical management

Medical management examples include weight loss, supportive bras, physical therapy, NSAIDs

Objective findings: Preoperative photographs confirm significant breast hypertrophy and shoulder grooving from bra straps and/or intertrigo when stated to be presentPhotographic confirmation

Required to document physical findings

Resection weight: Average grams of tissue to be removed per breast are above the 22nd percentile on the Schnur Sliding Scale based on body surface area OR regardless of BSA, more than 1,000 grams of breast tissue will be removed per breastSchnur >22nd percentile OR >1000 g per breast

Schnur Sliding Scale table provided in Appendix A

Cancer-related symmetry/staged procedures

Contralateral reduction for symmetry: Breast reduction on the non-diseased/contralateral breast performed to produce a symmetrical appearance following a mastectomy or lumpectomy is considered medically necessarySymmetry indication documented

Staged reduction prior to mastectomy: Breast reduction or mastopexy performed prior to a mastectomy is considered medically necessary when a staged procedure is planned prior to a nipple-sparing mastectomyPlanned staged approach documented

Coverage categories and criteria

Coverage stance for listed procedures

Medically necessary procedures: CPT 19316 (mastopexy) and CPT 19318 (breast reduction) are considered medically necessary when criteria in the applicable policy statements are met.

See main policy statements for specific clinical criteria.

Integral procedures not separately reimbursed: CPT 15877 (suction lipectomy) and CPT 19350 (nipple/areola reconstruction) are considered integral to and not separately reimbursed when performed with a medically necessary breast reduction.

Billing should not separately reimburse these codes when performed with a covered reduction.

Cosmetic/not medically necessary procedures: CPT 15839 (excision, excessive skin and subcutaneous tissue) and CPT 19355 (correction of inverted nipples) are considered cosmetic and not medically necessary.

These procedures may be excluded from coverage when billed for cosmetic indications.

Surgery performed solely to treat psychological or psychosocial complaints without significant physical findings that meet the policy criteria is considered cosmetic and not medically necessary. Requests for reduction mammaplasty must document objective physical findings (for example, shoulder grooving from bra straps, intertrigo at the inframammary fold, or other signs attributable to macromastia) and failure of conservative management to meet coverage criteria.

The following procedures are explicitly excluded as cosmetic/not medically necessary and are not covered when billed for medical necessity: CPT 15839 (excision, excessive skin and subcutaneous tissue) and CPT 19355 (correction of inverted nipples).

Suction lipectomy/liposuction (including ultrasonically assisted techniques) when used as the sole method of treatment for symptomatic macromastia is considered unproven and not medically necessary. The policy notes limited evidence that liposuction adequately removes glandular breast tissue and limited long‑term comparative data versus standard surgical reduction.

Excision of excessive skin and subcutaneous tissue (CPT 15839) and correction of inverted nipples (CPT 19355) are considered not medically necessary (cosmetic) and are excluded from coverage for medical indications under this policy.

Coding: Procedure Codes and Status

Considered Medically Necessary when criteria metCPTCovered

19316	Mastopexy
19318	Breast reduction

Integral/not separately reimbursable or considered cosmetic/not medically necessaryCPT

19350	Nipple/areola reconstruction
15877	Suction lipectomy (liposuction)
19355	Correction of inverted nipple

Considered Medically Necessary when criteria are metCPTCovered

19316	Mastopexy.
19318	Breast reduction.

Considered integral to and not separately reimbursed when performed with a medically necessary breast reductionCPT

15877	Suction assisted lipectomy; trunk.
19350	Nipple/areola reconstruction.

Considered Cosmetic/Not Medically NecessaryCPT

15839	Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area.
19355	Correction of inverted nipples.

Considered Unproven when performed as a sole method of treatment for symptomatic macromastiaCPTExperimental

15877

Suction assisted lipectomy; trunk.

Resection weight threshold (Schnur Sliding Scale)

Absolute weight rule>1,000 grams (more than 1 kg) of breast tissue to be removed per breast regardless of BSA

Source table referenceSchnur Sliding Scale table (Appendix A) provides BSA-specific cutoff weights (see Body Surface Area and Cutoff Weight table)

Provider Actions: Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for primary breast procedures when medically necessary criteria are met. Ensure requests include documentation that meets policy criteria before submitting for review.

Prior authorization implied for reduction mammoplasty (CPT 19318) and mastopexy (CPT 19316) when policy criteria are satisfied
Requests for procedures that are cosmetic or non-covered will be denied

Denial Risk

Cosmetic / Denial Risk

Services coded with CPT 15839 or CPT 19355 are considered cosmetic and not medically necessary; submit such services with caution as they may be denied.

Background: Clinical Context and Rationale

Macromastia is characterized by excessive breast hypertrophy that produces persistent symptoms such as neck, shoulder or upper back pain, bra‑strap grooving, and skin problems (for example, intertrigo or dermatitis at the inframammary fold). Reduction mammaplasty removes substantial breast tissue and skin to relieve these symptoms and is generally deferred until the breasts are mature; documented objective findings and failure of conservative therapy are required to support medical necessity.

Definitions

Macromastia — definition and example symptoms/signs

DefinitionMacromastia (female breast hypertrophy) — abnormally large breasts causing persistent signs and painful symptoms that distinguish it from large, asymptomatic breasts

Common symptoms/signsShoulder, upper back/neck pain; bra strap grooving; intertrigo, dermatitis, eczema, or hidradenitis at the inframammary fold

Clinical consequenceExcessive breast weight can lead to poor posture, thoracic kyphosis, occipital headaches, and neurologic symptoms from brachial plexus/ulnar nerve compression

Schnur Sliding Scale — tool description and thresholds

Tool descriptionSchnur Sliding Scale estimates expected resection weight relative to body surface area (BSA) using percentile cutoff values

Policy threshold

Policy Summary

PayerCigna

PolicyBreast Reduction

Policy CodePolicy 0152

Change TypeAnnual review — addition

Effective Date11/15/2025

Next Review Date08/15/2026

Key ActionObtain and document prior authorization and preoperative photographs and supporting documentation to demonstrate medical necessity for breast reduction.

SourceLink

On This Page

Unproven procedures: CPT 15877 (suction assisted lipectomy; trunk) is considered unproven when used as the sole method of treatment for symptomatic macromastia.

May be denied or require an alternative established surgical approach for coverage.

15839 — Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area: considered cosmetic/not medically necessary

19355 — Correction of inverted nipples: considered cosmetic/not medically necessary

Billing Rule

Suction-Assisted Lipectomy (15877) — Billing Guidance

Suction-assisted lipectomy of the trunk (CPT 15877) when performed in combination with a medically necessary breast reduction is considered integral to the reduction and is not separately reimbursable. However, when performed as the sole method to treat symptomatic macromastia, it is considered unproven and not medically necessary.

15877 — Considered integral and not separately reimbursed when performed with a medically necessary breast reduction (CPT 19318)
15877 — Considered unproven and not medically necessary when used as the sole treatment for symptomatic macromastia

Step Therapy

Step Therapy Preference — Liposuction-Only Reduction

Step therapy preference: liposuction-only breast reduction (CPT 15877 as sole treatment) is not an accepted primary treatment for symptomatic macromastia and is considered unproven. Preferred, established procedures (e.g., reduction mammoplasty CPT 19318) should be used when medical criteria are met.

Do not submit CPT 15877 alone as primary therapy for symptomatic macromastia — it is unproven and may be denied
Use CPT 19318 (reduction mammoplasty) or CPT 19316 (mastopexy) with appropriate documentation when criteria are satisfied

Documentation Required

Document conservative therapy attempts and required preoperative findings. Include preoperative photographs and documentation of physical findings to support medical necessity.

Conservative/medical management should be attempted and documented (e.g., weight loss, physical therapy, adequate bra support, NSAIDs, chiropractic/massage where applicable)
Preoperative photographs confirming significant breast hypertrophy and, if present, shoulder grooving or intertrigo
Document average grams of tissue expected to be removed per breast using the Schnur Sliding Scale or documentation that >1 kg will be removed per breast

Billing Rule

Provider Billing Actions and Denial Triggers

Billing guidance and denial triggers: follow coding rules to avoid denials. Claims with non-covered procedure codes or cosmetic procedures will be denied.

Bill CPT 19318 and 19316 when medically necessary and supported by documentation and prior authorization as applicable
Do not separately bill CPT 19350 or CPT 15877 when performed as integral parts of a medically necessary breast reduction (they are not separately reimbursable in that context)
Services coded with CPT 15839 or CPT 19355 are cosmetic/not medically necessary and may be denied if billed for coverage
CPT 15877 as the sole treatment for symptomatic macromastia is unproven and may be denied

22nd percentile cutoff on the Schnur Sliding Scale based on BSA

Alternative absolute thresholdOr, regardless of BSA, removal of more than 1 kg (1,000 g) per breast meets the threshold

Reduction mammaplasty — definition

DefinitionReduction mammaplasty (breast reduction) — surgical excision of a substantial portion of the breast, including skin and glandular tissue, to obtain a clinically normal breast size; nipple relocation may be required

Indication contextPerformed to relieve symptoms of macromastia when coverage criteria are met and breasts are mature (typically ≥18 years or completed growth)

Risks/considerationsMay decrease nipple sensation and lactation; complications include delayed wound healing, seroma, scarring, and higher risks with BMI ≥30 kg/m2 or smoking

Excision of redundant skin — definition

DefinitionExcision of redundant skin — procedure to correct tissue protruding at the end of a breast reduction incision or scar (e.g., dog ear/standing cone correction)

Policy noteSpecifically added to the policy statements in the Annual Review (8/15/2025)

Coverage implicationAddressed in policy language as an added statement for clarification of procedure scope