ModifiedKaiser PermanentePolicy N/A

Breast Reduction (Mammoplasty) Surgery

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This policy governs medical-necessity review and authorization for breast reduction surgery for Kaiser Foundation Health Plan of Washington members and providers. Coverage is distinguished from cosmetic breast surgery and requires clinical, symptom, treatment-failure, risk, and documentation criteria.

Policy Summary

PayerKaiser Permanente

PolicyBreast Reduction (Mammoplasty) Surgery

Policy CodePolicy N/A

Change TypeModified

Effective DateFebruary 1, 2027

Last ReviewJun 9, 2026

Next Review DateN/A

Key ActionVerify authorization requirements for breast reduction (CPT 19318) and submit documentation showing that all applicable criteria are met.

SourceLink

POLICY UPDATE CHANGES

Kaiser Permanente approved adoption of the Kaiser Permanente National Breast Reduction Mammoplasty criteria.

BMI-specific breast-tissue removal parameters, preoperative mammography, and smoking-cessation requirements were previously added under the MCG criteria.

A case-by-case pathway was added for younger patients with surgeon documentation of appropriateness, full physical maturity, and patient and guardian understanding.

18+Standard minimum age

≤35Maximum BMI criterion

6 monthsActivities-of-daily-living interference

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ModifiedKaiser PermanentePolicy N/A

Breast Reduction (Mammoplasty) Surgery

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Policy Summary

PayerKaiser Permanente

PolicyBreast Reduction (Mammoplasty) Surgery

Policy CodePolicy N/A

Change TypeModified

Effective DateFebruary 1, 2027

Last ReviewJun 9, 2026

Next Review DateN/A

Key ActionVerify authorization requirements for breast reduction (CPT 19318) and submit documentation showing that all applicable criteria are met.

SourceLink

POLICY UPDATE CHANGES

Kaiser Permanente approved adoption of the Kaiser Permanente National Breast Reduction Mammoplasty criteria.

BMI-specific breast-tissue removal parameters, preoperative mammography, and smoking-cessation requirements were previously added under the MCG criteria.

A case-by-case pathway was added for younger patients with surgeon documentation of appropriateness, full physical maturity, and patient and guardian understanding.

18+Standard minimum age

≤35Maximum BMI criterion

6 monthsActivities-of-daily-living interference

2+Required symptoms or functional effects

200/250/450 gPredicted tissue removal

19318Listed procedure code

Medical Necessity and Coverage Criteria

Medical necessity criteria for reduction mammoplasty

Reduction mammoplasty may be indicated when ALL of the following requirements are met:

All medical-necessity requirements

Age: The patient is age 18 or older, OR a younger patient is approved case-by-case with surgeon documentation confirming appropriateness, full physical maturity, and full understanding by the patient and guardians of the full nature of the surgery.18 years or older
Predicted tissue removal by BMI: Predicted removal from the larger breast is at least 200 grams when BMI is less than 25, at least 250 grams when BMI is 25–30, or at least 450 grams when BMI is greater than 30 and less than 35.200/250/450 grams by BMI category
Body and breast size: BMI is 35 or less, and breast size is D cup or above.BMI ≤35; D cup or above
Functional interference and symptoms
- Qualifying symptoms or findings: The patient has at least 2 of the following: chronic breast pain not relieved with hormonal adjustments or analgesics; persistent redness or erythema (intertrigo) below the breasts despite adequate medical treatment; upper or lower back pain; thoracic kyphosis; shoulder pain; severe bra-strap grooving or shoulder ulceration; arm pain or numbness consistent with brachial plexus compression syndrome; cervical pain; or nipple position greater than 21 cm below the suprasternal notch.At least 2
Failed nonsurgical treatment: Symptoms have not been relieved with at least 1 nonsurgical treatment: a trial of nonsteroidal anti-inflammatory drugs; exercise and/or physical therapy; wound care for skin ulceration; topical or oral antifungal agents for intertrigo; regular use of adequate support garments; or a medically supervised weight-loss program for an overweight or obese patient.At least 1 treatment trial
Preoperative medical and surgical conditions: Cosmetic breast implants are removed before glandular reduction at the patient's expense; women age 40 or older have no evidence of breast cancer and a normal mammogram within the past year; and the patient has no diagnosis of diabetes mellitus or has diabetes mellitus with A1c less than 8.0 within the last 3 months.Mammogram within the past year for women ≥40; A1c <8.0 when diabetic
Tobacco-use requirement: For members with a history of tobacco-product use, there is either a documented quit date more than 6 months before referral for consultation or a negative urine anabasine test below 3 ng/dL within the last 30 days if quit.Quit date >6 months before referral or anabasine <3 ng/dL within 30 days

Cosmetic services primarily intended to change or maintain appearance, or services not likely to result in significant improvement in physical function, are excluded as not medically necessary. Treatment for complications resulting from cosmetic services is not covered.

Cosmetic breast implants must be removed before glandular reduction, and the cost of implant removal is the patient’s responsibility.

Breast surgery indicated primarily to change or maintain appearance, or not likely to result in a significant improvement in physical function, is considered not medically necessary.

Covered Procedure and Clinical Thresholds

Considered Medically Necessary when applicable criteria are metCPTCovered

19318

Breast reduction

Age

Minimum age18 years or older

Younger patientsMay be approved case-by-case

Required documentation for younger patientsSurgeon documentation of appropriateness, full physical maturity, and full understanding by the patient and her guardians of the full nature of surgery

Predicted tissue removal when BMI <25

Applicable BMI rangeBMI less than 25

Minimum predicted removal200 grams of breast tissue

Measurement site

Authorization, Documentation, and Review Requirements

Prior Authorization

Prior Authorization Required for Covered Indication

Prior authorization is required for reduction mammoplasty when requested for a covered, medically necessary indication. CPT 19318 is considered medically necessary only when the applicable clinical criteria are met; verify plan-specific authorization requirements using the Pre-authorization Code Check.

Covered code: CPT 19318 — Breast reduction.
Codes may not be all-inclusive, and deleted or otherwise inactive codes may not be covered.

Step Therapy

Document Failed Nonsurgical Treatment

Document failure to relieve symptoms with nonsurgical treatment before requesting reduction mammoplasty. At least one qualifying treatment trial is required.

Nonsteroidal anti-inflammatory drugs for neck, shoulder, upper or lower back, or breast pain.
Exercise and/or physical therapy.

Policy Background

Reduction mammoplasty is covered when it is determined to be medically necessary rather than cosmetic. The policy distinguishes reduction surgery for medical indications associated with large breast size—such as pain, skin problems, posture abnormalities, or functional interference—from procedures performed primarily to change appearance.

Key Definition

Cosmetic service

Appearance changeA service primarily intended to change appearance

Appearance maintenanceA service primarily intended to maintain appearance

Physical-function standardA service not likely to result in significant improvement in physical function

Policy Summary

PayerKaiser Permanente

PolicyBreast Reduction (Mammoplasty) Surgery

Policy CodePolicy N/A

Change TypeModified

Effective DateFebruary 1, 2027

Last ReviewJun 9, 2026

Next Review DateN/A

Key ActionVerify authorization requirements for breast reduction (CPT 19318) and submit documentation showing that all applicable criteria are met.

SourceLink

On This Page

From the larger of the two breasts

Predicted tissue removal when BMI 25–30

Applicable BMI rangeBMI 25–30

Minimum predicted removal250 grams of breast tissue

Measurement siteFrom the larger of the two breasts

Predicted tissue removal when BMI >30 and <35

Applicable BMI rangeBMI greater than 30 and less than 35

Minimum predicted removal450 grams of breast tissue

Measurement siteFrom the larger of the two breasts

BMI

Maximum BMI35

Required relationshipBMI must be less than or equal to 35

Criteria contextThe BMI limit applies to medical-necessity criteria for reduction mammoplasty

Breast size

Minimum breast sizeD cup

Accepted sizeD cup or above

Measurement basisBra size

Activities-of-daily-living interference

Minimum durationAt least 6 months

Required impactSignificant interference with activities of daily living

Required causeDirectly attributable to large breast size

Diabetes control

Without diabetesNo diagnosis of diabetes mellitus

With diabetesDiabetes mellitus with A1c less than 8.0

A1c timeframeWithin the last 3 months

Tobacco cessation testing

Quit-date pathwayDocumented quit date more than 6 months before referral for consultation

Testing pathwayNegative urine anabasine test below 3 ng/dL within the last 30 days if quit

Applicable populationMembers with a history of tobacco-product use

Nipple position

Anatomical landmarkSuprasternal notch

Minimum distanceGreater than 21 cm below the suprasternal notch

Qualifying findingNipple position greater than 21 cm below the suprasternal notch

Wound care for skin ulceration.

Topical or oral antifungal agents for intertrigo.

Regular use of adequate support garments.

Medically supervised weight loss for overweight or obese patients.

Cosmetic breast implants must be removed before glandular reduction, at the patient's expense.

Documentation Required

Records Required for Medical-Necessity Review

Send the clinical records needed for medical-necessity review with the request. The review should be supported by the requesting provider's documentation for the preceding six months, when available.

Last 6 months of clinical notes from the requesting provider and/or specialist or primary care physician.
Physical therapy notes, if applicable.
Plastic surgery consultation.
Most recent height and weight.

Documentation Required

Document Clinical Criteria

Clinical documentation must establish the criteria supporting medical necessity, including photographs, symptoms attributable to breast size, and the treatment history. Document significant interference with activities of daily living for at least six months and at least two qualifying symptoms or findings.

Include photographs in the clinical record.
Document qualifying symptoms or findings, such as chronic breast pain, intertrigo despite treatment, upper or lower back pain, thoracic kyphosis, shoulder pain, severe bra-strap grooving or ulceration, arm pain or numbness consistent with brachial plexus compression, cervical pain, or nipple position more than 21 cm below the suprasternal notch.
Document breast size of D cup or larger, BMI, and the predicted tissue removal from the larger breast: at least 200 g when BMI is less than 25; 250 g when BMI is 25–30; or 450 g when BMI is greater than 30 and less than 35.
Document failure of at least one qualifying nonsurgical treatment and the duration of symptom interference.

Denial Risk

Unmet Criteria May Result in Denial

Requests are at risk for denial when the clinical record does not demonstrate that all applicable medical-necessity criteria are met. Ensure the request addresses the following requirements and exceptions.

Patient is age 18 or older; for a younger patient, provide surgeon documentation confirming full physical maturity and the patient's and guardians' understanding of the surgery.
BMI is 35 or less; breast size is D cup or larger; and predicted removal meets the applicable BMI-based tissue threshold.
Significant interference with activities of daily living has lasted at least six months and includes at least two qualifying symptoms or findings.
Symptoms have not been relieved by qualifying nonsurgical treatment.
Women age 40 or older have no evidence of breast cancer and a normal mammogram within the past year.
There is no diabetes mellitus, or diabetes is controlled with an A1c below 8.0 within the last 3 months.
For members with a history of tobacco-product use, document a quit date more than 6 months before referral or a negative urine anabasine test below 3 ng/dL within the last 30 days if quit.
Any cosmetic breast implants have been removed before glandular reduction at the patient's expense.

Denial Risk

Cosmetic Indications Are Not Covered

Reduction mammoplasty and related services are not medically necessary when the primary purpose is cosmetic rather than functional. Services intended to change or maintain appearance, or that are unlikely to significantly improve physical function, are not covered, including treatment of complications resulting from cosmetic services.

Appearance-only indications are not covered.
Services unlikely to produce significant improvement in physical function are not covered.
Complications resulting from cosmetic services are not covered.

Denial Risk

Insufficient Documentation May Delay or Deny Review

Missing or incomplete supporting documentation may result in denial or a request for additional information before medical-necessity review can be completed. Submit the complete clinical record with the initial request.

Photographs supporting medical necessity.
Six months of clinical notes from the requesting provider and/or specialist or primary care physician.
Physical therapy notes, if applicable, and the plastic surgery consultation.
Most recent height and weight, symptom duration, qualifying symptoms, and impact on activities of daily living.
Documentation of failed nonsurgical treatment and applicable mammogram, A1c, and tobacco-use evidence.