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    v1.0.28
    OpenPayerPolicy UpdatesPlastic/Reconstructive SurgeryEmblemHealth Breast Reduction Coverage Update | Op…
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    CurrentEmblemHealthPolicy MG.MM.SU.01g2

    Breast Reduction Mammoplasty

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    Clinical criteria and coverage guidance for breast reduction (reduction mammoplasty) including documentation, eligibility, and exclusions for EmblemHealth members undergoing the procedure.

    Policy Summary
    PayerEmblemHealth
    PolicyBreast Reduction Mammoplasty
    Policy CodePolicy MG.MM.SU.01g2
    Change TypeMaterial clinical updates
    Effective DateApr 10, 2026
    Last ReviewJun 16, 2026
    Next Review DateApr 10, 2026
    Key ActionSubmit pre-service clinical documentation including physician progress notes, frontal and lateral breast photographs, and age-appropriate mammogram per guideline requirements.
    SourceLink
    POLICY UPDATE CHANGES

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

    Removed 'claims of inability to exercise' from Limitations/Exclusions.

    Amended Schnur scale note specifying the 'minimum' amount of breast tissue to be removed must be proportional to body surface area (BSA).

    ≥18Minimum age for eligibility
    ≥1 yrDuration of symptoms
    RequiredSchnur scale
    19316,19318Procedure CPT codes

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    N62ICD-10 code

    Coverage Criteria for Reduction Mammoplasty

    Medical necessity criteria

    Reduction mammoplasty is eligible when all criteria below are satisfied.

    Primary eligibility: Member meets all of the following:
    Age and development: Age ≥ 18 and completed pubertal and skeletal development.>=18

    Referenced in guideline (age and development requirement).

    Duration of symptoms: Presence of clinically significant and persistent symptoms that have caused functional impairment for ≥ 1 year.>=1 year

    Symptoms must be documented by the physician in progress notes as directly related to macromastia.

    Acceptable symptoms/objective findings: At least one of the following must be documented in the physician progress notes:
    Symptom option A: History of severe intertriginous dermatitis unresponsive to medical management.
    Symptom option B: Presence of thoracic or cervical pain syndrome (e.g., upper back, neck, or shoulder pain) not related to causes other than excessive breast weight and unresponsive to conservative treatment including analgesia and NSAIDs.

    Excludes lower back pain; must be unresponsive to conservative care.

    Symptom option C: Presence of ulnar nerve compression with documented paresthesia secondary to coracoid process descent.
    Symptom option D: Presence of dorsal kyphosis or compensatory lordosis documented by X-rays.
    Functional limitation: Inability to perform activities of daily living and/or inability to exercise.

    Added as a covered indication.

    Schnur scale requirement: Minimum amount of breast tissue to be removed must be proportional to body surface area (BSA) per the Schnur scale, with the estimated grams to be removed per breast provided at time of pre-service review.Schnur scale table

    BSA formula: BSA (m2) = ([height (cm) x weight (kg)]/3600)^(1/2); BSA calculator referenced.

    Breast reduction mammoplasty is considered not medically appropriate when the indication is limited to non-medical or non-functional concerns. Examples include fibrocystic disease, problems related to improperly fitting clothing, or concerns that are primarily psychological or social in nature. These situations do not meet the guideline’s requirements for documented persistent, functionally limiting symptoms and objective findings.

    Procedures performed solely for cosmetic reasons are excluded from coverage. This includes attempts to improve appearance where clinical criteria are not met, such as treating breast asymmetry when the member does not satisfy the medical necessity criteria listed elsewhere in the guideline. Note that mastopexy (breast lift) is only covered when performed in conjunction with a reconstructive procedure.

    Procedure and Diagnosis Coding

    Procedure CPT CodesCPTCovered
    19316Mastopexy
    19318Breast mammaplasty
    ICD-10 DiagnosesICD-10
    N62Hypertrophy of breast
    Schnur scale (minimum tissue removal proportional to BSA)
    RequirementMinimum amount of breast tissue to be removed must be proportional to body surface area (BSA) per the Schnur scale; estimate provided at pre-service review.
    BSA formulaBSA (m2) = ([height (cm) x weight (kg)] / 3600)^(1/2).
    Example Schnur ranges (selected from table)BSA 1.40–1.50 m2 → remove 218–260 g per breast (alternate entries in table list higher gram ranges for same BSA as shown in guideline).
    Pre-service actionProvide Schnur scale estimate (grams per breast) with preauthorization submission.

    Provider Actions and Documentation Requirements

    Prior Authorization

    Preauthorization documentation and imaging

    Submit a preauthorization (pre-service review) package that includes clinical documentation and breast photographs (unobstructed frontal and lateral views, shoulder to waist). For women age ≥ 40, or younger with a first‑degree family history of breast cancer, include a mammogram negative for cancer performed within 2 years of the scheduled surgery date.

    • Breast photographs: unobstructed frontal and lateral views, shoulder to waist
    • Mammogram: required if patient is ≥ 40, or younger with a first‑degree family history; must be negative for cancer within 2 years of scheduled surgery
    Step Therapy

    Conservative therapy requirement

    Document that conservative management was attempted and was ineffective for the reported symptom(s) before considering surgery — e.g., pain unresponsive to analgesia/NSAIDs or intertriginous dermatitis unresponsive to medical management.

    • Pain: note trial of analgesics and NSAIDs without sufficient relief

    Definitions

    Mastopexy
    DefinitionMastopexy: Plastic surgery to move sagging breasts into a more elevated position involving repositioning of the nipple and areola; sometimes performed with implants.
    Typical indicationPerformed to elevate ptotic breasts; may be done alone or in conjunction with implant insertion.
    Coding noteSee procedure CPT code 19316 (mastopexy) listed in procedure codes section.
    Reconstructive surgery
    Reconstructive surgeryPerformed on abnormal structures caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease to improve function or approximate a normal appearance (e.g., following mastectomy).
    PurposeGenerally performed to improve function but may also approximate a normal appearance.

    Background

    Reduction mammoplasty is performed to relieve the functional impairment from macromastia and may be considered reconstructive when aimed at achieving symmetry with a reconstructed breast. Medical indications focus on persistent, functionally limiting symptoms documented for ≥ 1 year (for example, severe intertriginous dermatitis unresponsive to medical management; thoracic/cervical pain syndrome not due to other causes and unresponsive to conservative therapy; ulnar nerve compression with documented paresthesia; or spinal compensatory changes shown on X‑ray). The guideline also recognizes inability to perform activities of daily living and/or inability to exercise as a covered indication. Pre-service review requires submission of clinical documentation and breast photographs, and an estimate of tissue removal proportional to body surface area per the Schnur scale.

    Revision History

    2026-06-16revisionLatest

    Removed 'claims of inability to exercise' from Limitations/Exclusions.

    2026-04-10revision

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

    2021-07-09clarification
    Policy Summary
    PayerEmblemHealth
    PolicyBreast Reduction Mammoplasty
    Policy CodePolicy MG.MM.SU.01g2
    Change TypeMaterial clinical updates
    Effective DateApr 10, 2026
    Last ReviewJun 16, 2026
    Next Review DateApr 10, 2026
    Key ActionSubmit pre-service clinical documentation including physician progress notes, frontal and lateral breast photographs, and age-appropriate mammogram per guideline requirements.
    SourceLink
    On This Page
    Coverage Criteria for Reduction MammoplastyProcedure and Diagnosis CodingProvider Actions and Documentation RequirementsDefinitionsBackgroundRevision History
  1. Dermatitis: note medical management tried and failed
    2. Documentation Required

    Required clinical documentation

    Provide physician progress notes that document symptoms and objective findings directly related to macromastia, including the specific acceptable findings listed in the guideline (e.g., severe intertriginous dermatitis unresponsive to medical management; thoracic or cervical pain syndrome not due to other causes; ulnar nerve compression with documented paresthesia; dorsal kyphosis or compensatory lordosis documented by X‑rays).

    • Progress notes documenting duration of symptoms (≥ 1 year) and functional impairment
    • Objective findings: dermatitis details, pain syndrome description and treatments tried, nerve compression documentation, X‑ray evidence of spinal changes
    Denial Risk

    Documentation required for review — consequences

    Failure to submit the clinical evidence and required documentation will prevent EmblemHealth from properly reviewing the preauthorization or post‑payment request.

    • Missing breast photographs or required mammogram may delay or prevent review
    • Absent physician progress notes or objective findings documentation may result in inability to determine medical necessity
    Relation to mastopexyMastopexy is covered when associated with a reconstructive procedure.
    Cosmetic surgery
    DefinitionCosmetic surgery: (term listed in definitions section of document).
    Coverage implicationProcedures performed solely for cosmetic reasons are not medically appropriate under this guideline.
    ExampleCosmetic procedures include those done solely to improve appearance, such as asymmetry not meeting medical necessity criteria.

    Amended Schnur scale note specifying the 'minimum' amount of breast tissue to be removed must be proportional to body surface area (BSA).

    2024-03-27addition

    Added note regarding medical necessity of preparatory mastopexy or reduction mammaplasty prior to mastectomy for certain patients.