CurrentConnectiCarePolicy MG.MM.SU.01

Breast Reduction Mammoplasty

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ConnectiCare coverage and prior authorization for breast reduction mammoplasty and associated reconstructive mastopexy, including medical-necessity documentation, qualifying symptoms, tissue-removal thresholds, photographs, and age- and risk-based mammography.

Policy Summary

PayerConnectiCare

PolicyBreast Reduction Mammoplasty

Policy CodePolicy MG.MM.SU.01

Change TypeMaterial policy update

Effective DateApr 10, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence, unobstructed frontal and lateral breast photographs, and any required negative mammogram for prior authorization.

SourceLink

POLICY UPDATE CHANGES

Added inability to perform activities of daily living and/or inability to exercise as a covered indication.

Added coverage for preparatory mastopexy or reduction mammoplasty before nipple-sparing mastectomy in selected patients with macromastia or breast ptosis and elevated breast cancer risk.

Revised the intertriginous dermatitis indication to require a history of severe dermatitis unresponsive to medical management.

≥18Minimum age

≥1 yearRequired symptom duration

4Qualifying categories

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CurrentConnectiCarePolicy MG.MM.SU.01

Breast Reduction Mammoplasty

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Policy Summary

PayerConnectiCare

PolicyBreast Reduction Mammoplasty

Policy CodePolicy MG.MM.SU.01

Change TypeMaterial policy update

Effective DateApr 10, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence, unobstructed frontal and lateral breast photographs, and any required negative mammogram for prior authorization.

SourceLink

POLICY UPDATE CHANGES

Added inability to perform activities of daily living and/or inability to exercise as a covered indication.

Added coverage for preparatory mastopexy or reduction mammoplasty before nipple-sparing mastectomy in selected patients with macromastia or breast ptosis and elevated breast cancer risk.

Revised the intertriginous dermatitis indication to require a history of severe dermatitis unresponsive to medical management.

≥18Minimum age

≥1 yearRequired symptom duration

4Qualifying categories

≥40Mammogram age trigger

2 yearsMammogram lookback

218–1,275 gTissue-removal range

Medical Necessity and Coverage Criteria

Initial medical-necessity criteria

Covered when all core criteria are met and at least one qualifying symptom or objective-finding category is documented.

Core eligibility and medical necessity

Member is at least 18 years old and has completed pubertal and skeletal development.Age ≥18
Clinically significant and persistent symptoms have caused functional impairment for at least 1 year.Symptoms with functional impairment ≥1 year
Inability to perform activities of daily living and/or inability to exercise is documented.Functional impairment involving daily activities and/or exercise
The minimum proposed tissue removal per breast is proportional to body surface area under the Schnur scale.Minimum tissue-removal amount based on BSA; estimate provided at pre-service review
ONE or more qualifying macromastia-related symptom or objective-finding categories
- History of severe intertriginous dermatitis unresponsive to medical management.Unresponsive to medical management
- Thoracic or cervical pain syndrome, such as upper back, neck, or shoulder pain, excluding lower back pain, not related to another cause and unresponsive to conservative treatment including analgesia and nonsteroidal anti-inflammatory medications.Unresponsive to analgesia and nonsteroidal anti-inflammatory medications
- Ulnar nerve compression with documented paresthesia secondary to coracoid process descent.Documented paresthesia
- Dorsal kyphosis or compensatory lordosis documented by X-rays.X-ray documentation required

Reconstructive and pre-mastectomy indications

Covered for reconstructive symmetry or selected pre-mastectomy preparation when the stated circumstances apply.

Reconstructive indications

Reduction mammoplasty is performed to achieve symmetry of the non-cancerous breast to the reconstructed breast after breast cancer surgery, regardless of the size of the unaffected breast.
Preparatory mastopexy or reduction mammoplasty is medically necessary before a planned nipple-sparing mastectomy in a woman with macromastia and/or breast ptosis who has a genetic mutation such as BRCA1 or BRCA2 and/or an elevated risk of breast cancer.Before planned nipple-sparing mastectomy

Age- and risk-based mammography

Additional preoperative requirements apply based on age and family history.

ONE of the following triggers applies

The woman is age 40 or older.Age ≥40
The woman is younger than 40 and has a positive family history of breast cancer in a first-degree relative.
When either trigger applies, documentation includes a mammogram negative for cancer performed within 2 years before the scheduled surgery date.Negative mammogram within 2 years

Breast reduction mammoplasty is not medically appropriate when requested for claims of inability to exercise, fibrocystic disease, improperly fitting clothing, psychological or social reasons, or any other solely cosmetic reason to improve appearance, including breast asymmetry when the member does not meet the policy criteria.

Requests based solely on inability to exercise, fibrocystic disease, improperly fitting clothing, psychological or social reasons, or cosmetic appearance improvement are not medically necessary under this policy. This includes breast asymmetry when the member does not meet the stated medical-necessity criteria.

Procedure, Diagnosis, and Tissue-Removal Coding

Covered CPT CodesCPTCovered

19316	Mastopexy
19318	Breast mammaplasty

Diagnosis CodesICD-10

N62	Hypertrophy of breast

Schnur Scale: Initial BSA Bands

BSA 1.40–1.50218–260 g of tissue per breast

BSA 1.51–1.60261–310 g of tissue per breast

BSA 1.61–1.70311–370 g of tissue per breast

Schnur Scale: Remaining BSA Bands

BSA 1.71–1.80371–441 g of tissue per breast

BSA 1.81–1.90442–527 g of tissue per breast

BSA 1.91–2.00

Prior Authorization and Documentation Requirements

Prior Authorization

Submit Clinical Evidence for Prior Authorization

The treating physician or primary care provider must submit clinical evidence demonstrating that the member meets the criteria for breast reduction mammoplasty. Without the required documentation and information, ConnectiCare cannot properly review the prior authorization request.

Submit clinical documentation supporting medical necessity and the planned surgical procedure.
Reduction mammoplasty may be approved to achieve symmetry of the non-cancerous breast to the reconstructed breast after breast cancer surgery, regardless of the unaffected breast size.
For certain women with macromastia and/or breast ptosis who are planning nipple-sparing mastectomy for a genetic mutation or elevated breast-cancer risk, preparatory mastopexy or reduction mammoplasty before mastectomy may be medically necessary.

Documentation Required

Include Required Photographs and Mammography

The provider is responsible for submitting complete clinical documentation, including required photographs and mammography when applicable, for plan review.

Policy Background

Breast reduction mammoplasty removes breast tissue to address symptoms associated with macromastia and related functional impairment. The clinical focus includes persistent intertriginous dermatitis, upper back, neck, or shoulder pain, nerve compression, and spinal-posture abnormalities, together with impairment in activities of daily living or exercise. Tissue removal is evaluated in proportion to body surface area under the Schnur scale. Reconstructive reduction or mastopexy may also support breast symmetry after breast cancer reconstruction or, in selected high-risk patients, preparation for nipple-sparing mastectomy.

Relevant Surgical Definitions

Cosmetic Surgery

ProcedureSurgery performed to reshape normal structures of the body.

PurposeTo improve the patient's appearance and self-esteem.

Policy classificationCosmetic surgery concerns reshaping normal body structures rather than correcting abnormal structures.

Mastopexy

ProcedurePlastic surgery to move sagging breasts into a more elevated position.

RepositioningIt involves repositioning the nipple and areola.

Additional procedure

Policy Summary

PayerConnectiCare

PolicyBreast Reduction Mammoplasty

Policy CodePolicy MG.MM.SU.01

Change TypeMaterial policy update

Effective DateApr 10, 2026

Next Review DateN/A

Key ActionSubmit clinical evidence, unobstructed frontal and lateral breast photographs, and any required negative mammogram for prior authorization.

SourceLink

On This Page

528–628 g of tissue per breast

BSA 2.01–2.10629–750 g of tissue per breast

BSA 2.11–2.20751–895 g of tissue per breast

BSA 2.21–2.30896–1,068 g of tissue per breast

BSA 2.31–2.401,069–1,275 g of tissue per breast

Submit unobstructed frontal and lateral breast photographs showing the member from shoulder to waist.
For women age 40 or older, submit documentation of a mammogram negative for cancer within the 2 years before the scheduled surgery date.
For members younger than 40, submit the same negative mammogram documentation when there is a positive breast-cancer family history in a first-degree relative.

Documentation Required

Document Medical Necessity and Planned Tissue Removal

Progress notes must document persistent symptoms and objective findings as directly related to macromastia, the duration and functional impact of those symptoms, conservative treatment provided, and the amount of tissue planned for removal.

Document clinically significant, persistent symptoms causing functional impairment for at least 1 year.
Document inability to perform activities of daily living and/or inability to exercise.
Document the planned minimum tissue removal as proportional to body surface area under the Schnur scale, with the estimate provided at pre-service review.
When applicable, document the required treatment history, including failure of medical management for dermatitis or failure of analgesia and nonsteroidal anti-inflammatory medications for pain.

Documentation Required

Document Qualifying Symptoms and Objective Findings

The progress notes must identify at least one qualifying symptom or objective finding directly related to macromastia and include supporting clinical evidence.

Severe intertriginous dermatitis that is unresponsive to medical management.
Thoracic or cervical pain syndrome, including upper-back, neck, or shoulder pain, excluding lower-back pain, that is not attributable to another cause and is unresponsive to conservative treatment, including analgesia and nonsteroidal anti-inflammatory medications.
Ulnar nerve compression with documented paresthesia secondary to coracoid process descent.
Dorsal kyphosis or compensatory lordosis documented by X-rays.

Denial Risk

Failure to Meet Medical-Necessity Criteria

A request is at risk for denial when the member does not satisfy every medical-necessity requirement for reduction mammoplasty. All criteria must be met and supported in the clinical record.

Member must be age 18 or older and have completed pubertal and skeletal development.
Symptoms must be clinically significant, persistent, directly related to macromastia, and associated with functional impairment for at least 1 year.
The record must support inability to perform activities of daily living and/or inability to exercise, along with qualifying symptoms or objective findings.
The estimated minimum tissue removal must be proportional to body surface area under the Schnur scale. The source table identifies the following provided ranges: BSA 1.40–1.50: 218–260 g or 528–628 g per breast; BSA 1.51–1.60: 261–310 g or 629–750 g per breast; BSA 1.61–1.70: 311–370 g or 751–895 g per breast; the estimate is required at pre-service review.
Failure to provide the required progress-note documentation, objective findings, conservative-treatment history, functional impairment, or planned tissue-removal estimate may prevent approval.

Denial Risk

Excluded Indications

Breast reduction mammoplasty is not medically appropriate when the request is based solely on excluded indications. Mastopexy is covered when associated with a reconstructive procedure.

Inability to exercise alone.
Fibrocystic disease.
Improperly fitting clothing.
Psychological or social reasons.
A solely cosmetic reason to improve appearance, including breast asymmetry when the member does not meet the stated medical-necessity criteria.

Denial Risk

Required Photographs Not Submitted

Required photographs must be submitted for review. Missing, obstructed, or inadequate photographs may prevent ConnectiCare from evaluating the request and may result in nonapproval.

Provide an unobstructed frontal view of both breasts from shoulder to waist.
Provide an unobstructed lateral view of the breasts from shoulder to waist.
Ensure the photographs clearly permit review of the breast condition and planned reduction.

Denial Risk

Required Mammography Not Documented

Document mammography when required by age or family history. The mammogram must be negative for cancer and completed within 2 years before the scheduled surgery date.

Required for women age 40 or older.
Also required for younger members with a positive breast-cancer family history in a first-degree relative.
Failure to document the applicable mammogram may prevent approval of the request.

It is sometimes performed in conjunction with implant insertion.

Reconstructive Surgery

対象 structuresSurgery performed on abnormal structures of the body.

CausesThe abnormal structures may be caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease.

PurposeIt is generally performed to improve function but may also be done to approximate a normal appearance, such as following a mastectomy for breast cancer.