CurrentEmblemHealthPolicy MG.MM.SU.01fC4

Breast Reduction Mammoplasty

This clinical policy describes EmblemHealth's medical necessity criteria, documentation and coding guidance for reduction mammoplasty (breast reduction) and associated mastopexy when reconstructive, for members covered under EmblemHealth plans.

Policy Summary

PayerEmblemHealth

PolicyBreast Reduction Mammoplasty

Policy CodePolicy MG.MM.SU.01fC4

Change TypeMaterial updates to criteria and documentation

Effective Date

Next Review DateApr 11, 2025

Key ActionSubmit preauthorization with clinical documentation and breast photographs demonstrating all medical necessity criteria are met, including Schnur scale tissue removal estimates and applicable mammography.

SourceLink

POLICY UPDATE CHANGES

Added note that preparatory mastopexy or reduction mammaplasty prior to mastectomy may be medically necessary in certain women with macromastia and/or ptosis undergoing nipple-sparing mastectomy for genetic mutations or elevated cancer risk.

Intertriginous dermatitis criterion wording changed from 'Presence' to 'History' and photo language was modified previously.

Clarified that the minimum amount of breast tissue to be removed must be proportional to body surface area (BSA) per the Schnur scale.

>= 18Minimum age for eligibility

>= 1 yearDuration of persistent functional symptoms required

Schnur scale

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Minimum tissue removal proportional to BSA required

Within 2 yrsMammogram requirement

2 codesProcedure codes listed

Coverage and Medical Necessity Criteria

Initial eligibility and medical necessity

Covered when ALL of the following are met:

Overall coverage requirements: Member meets each numbered criterion below

Criterion 1: Age ≥ 18 and completed pubertal and skeletal development>=18 years

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Criterion 2: Clinically significant and persistent symptoms causing functional impairment for ≥ 1 year with physician-documented progress notes showing symptoms directly related to macromastia>=1 year

Symptoms include history of severe intertriginous dermatitis unresponsive to medical management; thoracic or cervical pain syndrome (upper back, neck, shoulder) not related to other causes and unresponsive to conservative treatment including analgesia and NSAIDs; ulnar nerve compression with documented paresthesia secondary to coracoid process descent; dorsal kyphosis or compensatory lordosis documented by X-rays

Criterion 3: Minimum amount of breast tissue to be removed must be proportional to body surface area (BSA) per the Schnur scale; estimated grams to be removed per breast must be provided at pre-service reviewSchnur scale table

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Additional requirement: For women ≥ 40, or younger with a first-degree family history of breast cancer, a negative mammogram within the last 2 years of the scheduled surgery date must be documentedNegative mammogram within 2 years

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Reconstructive / Symmetry indications

Covered when meeting reconstructive symmetry criteria:

Reconstruction symmetry: Reduction mammoplasty is approved to achieve symmetry of the non-cancerous breast to the reconstructed breast after breast cancer surgery, regardless of the size of the unaffected breast

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Preparatory procedure before mastectomy: In certain women with macromastia and/or breast ptosis planned for nipple-sparing mastectomy for a genetic mutation (e.g., BRCA1/2) or elevated breast cancer risk, preparatory mastopexy or reduction mammaplasty prior to the mastectomy may be medically necessary

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Breast reduction mammoplasty is not medically appropriate for requests that are solely cosmetic. Examples include claims of inability to exercise, fibrocystic disease, improperly fitting clothing, psychological or social reasons, or any other purely aesthetic reason to improve appearance.

Mastopexy is covered only when associated with a reconstructive procedure. Isolated mastopexy performed for cosmetic breast lifting or contouring does not meet coverage criteria.

Requests for breast procedures driven solely by cosmetic concerns are considered not medically necessary. This includes correction of breast asymmetry when the member does not meet the policy's medical necessity criteria for reduction mammoplasty or reconstructive symmetry—such cases are excluded from coverage.

Procedure and Diagnosis Coding; Schnur Scale

Procedure CodesCPTCovered

19316	Mastopexy
19318	Breast mammaplasty

ICD-10 DiagnosesICD-10

N62	Hypertrophy of breast

inv-08: Schnur scale tissue removal per breast — gram ranges tied to BSA bands.

Schnur scale — BSA 1.40–1.50 m2Grams of tissue to be removed per breast = 218–260 g (alternative row shows 528–628 g)

Schnur scale — BSA 1.51–1.60 m2Grams of tissue to be removed per breast = 261–310 g (alternative row shows 629–750 g)

Schnur scale — BSA 1.61–1.70 m2Grams of tissue to be removed per breast = 311–370 g (alternative row shows 751–895 g)

Schnur scale — BSA 1.71–1.80 m2Grams of tissue to be removed per breast = 371–441 g (alternative row shows 896–1,068 g)

Schnur scale — BSA 1.81–1.90 m2Grams of tissue to be removed per breast = 442–527 g (alternative row shows 1,069–1,275 g)

Preauthorization, Documentation, and Submission Requirements

Prior Authorization

Prior Authorization Required

Preauthorization is required for reduction mammoplasty. Submit pre-service review with clear clinical documentation and breast photographs (unobstructed frontal and lateral views, shoulder to waist). For women ≥ 40, or younger with a first‑degree family history of breast cancer, include a negative mammogram within 2 years of the scheduled surgery date.

Preauthorization required for reduction mammoplasty
Breast photographs: unobstructed frontal and lateral views, shoulder to waist
Mammogram (women ≥ 40 or younger with first‑degree family history) — negative within 2 years of surgery

Documentation Required

Conservative Management Expectation

Conservative (nonoperative) management must be attempted and documented for thoracic or cervical pain syndromes attributed to macromastia prior to approval. Documentation should show the syndrome is not related to other causes and that symptoms were unresponsive to conservative treatment including analgesics and NSAIDs.

Background and Context

Reduction mammoplasty (breast reduction) is performed to relieve functional symptoms attributable to macromastia and to achieve symmetry with a reconstructed breast. Coverage is determined by documented duration and severity of symptoms, objective proportionality of planned tissue removal using the Schnur scale, and required imaging when applicable. For women aged ≥ 40 (or younger with a first-degree family history of breast cancer), a negative mammogram within the prior 2 years must be provided. Pre-service review requires submission of clinical documentation including photographs, physician progress notes, BSA and planned grams to be removed per breast, and evidence of attempted conservative management where relevant.

Key Definitions

inv-16: Cosmetic surgery — definition and intent.

DefinitionPerformed to reshape normal structures of the body to improve the patient's appearance and self‑esteem.

IntentPrimary intent is cosmetic — to improve appearance and self‑esteem rather than restore function.

Coverage implicationProcedures performed solely for cosmetic reasons are considered not medically necessary under this policy.

inv-17: Mastopexy — definition describing repositioning of nipple/areola.

DefinitionPlastic surgery to move sagging breasts into a more elevated position; it involves repositioning of the nipple and areola.

Additional detailMastopexy is sometimes performed in conjunction with implant insertion.

Policy Summary

PayerEmblemHealth

PolicyBreast Reduction Mammoplasty

Policy CodePolicy MG.MM.SU.01fC4

Change TypeMaterial updates to criteria and documentation

Effective Date

Next Review DateApr 11, 2025

SourceLink

On This Page

inv-09: Mammography timing requirement — negative mammogram within 2 years for women ≥40 or younger with first-degree family history.

Mammography timing requirementFor women ≥ 40, or younger with a positive first‑degree family history of breast cancer, documentation must include a mammogram negative for cancer within the last 2 years of the scheduled surgery date.

Applies to younger women with family historyYounger women require the negative mammogram only if there is a positive family history in a first‑degree relative.

Documentation required at pre-service reviewNegative mammogram must be submitted with the other preoperative documentation (e.g., photos, clinical notes).

Conservative treatment attempted for thoracic/cervical pain (analgesia and NSAIDs) and documented as ineffective
Pain must be clearly attributable to excessive breast weight and not other causes

Documentation Required

Documentation Required for Review

EmblemHealth requires complete clinical documentation at the time of review. Failure to submit adequate records may prevent proper review and can result in denial. The treating physician must provide progress notes that document symptoms, duration (≥ 1 year for functional impairment), objective findings related to macromastia, and the estimated grams of tissue to be removed per breast (Schnur scale) with the BSA calculation method.

Physician progress notes documenting symptoms, duration (≥ 1 year), and objective findings
Estimated grams of tissue to be removed per breast with Schnur scale calculation and BSA (include height and weight or BSA value)
Breast photographs as specified (frontal and lateral, shoulder to waist)
For women ≥ 40 or with relevant family history, include negative mammogram within 2 years

Denial Risk

Non‑Covered Indications

Requests solely for cosmetic purposes are not covered. Examples of non‑covered indications include claims based only on inability to exercise, improperly fitting clothing, fibrocystic disease, psychological or social reasons, or any other reason solely to improve appearance. Mastopexy that is not associated with a reconstructive procedure is considered cosmetic and not covered.

Not covered: inability to exercise, improperly fitting clothing, fibrocystic disease, psychological/social reasons, any solely cosmetic reason
Mastopexy is covered only when associated with a reconstructive procedure

Coverage noteMastopexy is covered by this policy only when associated with a reconstructive procedure or as part of medically necessary care described in the policy.

inv-18: Reconstructive surgery — definition for procedures to restore function or normal appearance after disease/trauma.

DefinitionPerformed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to improve function or approximate a normal appearance.

Primary purposeGenerally performed to improve function, though may also be done to approximate normal appearance (e.g., following mastectomy).

Relevance to policyReconstructive procedures (including preparatory mastopexy or reduction prior to mastectomy in select high‑risk patients) may be medically necessary under this policy.