CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Reduction Mammoplasty

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This guideline explains the clinical information and medical-necessity criteria MassHealth uses to review prior-authorization requests for reduction mammoplasty, including requests for adults, adolescents ages 15 through 17, and case-by-case requests for members under age 15.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Reduction Mammoplasty

Policy CodePolicy N/A

Change TypeRevisedno material clinical or coverage change

Effective DateMay 26, 2023

Next Review DateN/A

Key ActionSubmit the prior-authorization request and supporting documentation through the Provider Online Service Center or MassHealth PA-1 paper form.

SourceLink

POLICY UPDATE CHANGES

The guideline was revised effective May 26, 2023 and supersedes the policy dated July 24, 2019.

PA requiredPrior authorization requirement for reduction mammoplasty

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CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Reduction Mammoplasty

Customize your policy alerts

Sign up for all Massachusetts Executive Office of Health and Human Services policy alerts

Know when Massachusetts Executive Office of Health and Human Services releases new policies or updates existing guidance.

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Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Reduction Mammoplasty

Policy CodePolicy N/A

Change TypeRevisedno material clinical or coverage change

Effective DateMay 26, 2023

Next Review DateN/A

Key ActionSubmit the prior-authorization request and supporting documentation through the Provider Online Service Center or MassHealth PA-1 paper form.

SourceLink

POLICY UPDATE CHANGES

The guideline was revised effective May 26, 2023 and supersedes the policy dated July 24, 2019.

PA requiredPrior authorization requirement for reduction mammoplasty

Adult clinical criteria that must all be met

Within 1 yearRequired timeframe for conservative treatment trials for pain symptoms

Age 40+Members who must have a negative screening mammogram within 2 years of surgery

Age 15-17Adolescent population eligible under defined clinical and growth-stabilization criteria

Size C or smallerNormal breast size excluded from coverage

Reduction Mammoplasty Coverage Criteria

Adult coverage criteria

Covered for adults when all of the following criteria are met, including at least one qualifying persistent symptom criterion.

Adult clinical coverage

Required adult criteria
- Age: The member is age 18 or older.Age 18 or older
- Sex: The member is female.
- Clinical evaluation: A comprehensive medical history and complete physical examination, including a breast examination, have been conducted by the referring health care provider.
- Diagnosis and breast size: The member has a diagnosis of breast hypertrophy, gigantomastia, or macromastia, with breast size D or higher.Size D or higher
- Surgical plan: The treating surgeon specifies the amount of tissue to be removed from each breast and the prognosis for improvement of symptoms related to breast hypertrophy, gigantomastia, or macromastia.
- Exclusion of other causes: Other etiologies of the symptoms have been excluded.
Qualifying persistent symptom
- Back pain is unresponsive to conservative treatment within the year before the request. Conservative treatment includes a documented trial of analgesics and physical therapy or chiropractic treatment.Within 1 year before the request
- Neck pain is unresponsive to conservative treatment within the year before the request. Conservative treatment includes a documented trial of analgesics and physical therapy or chiropractic treatment.Within 1 year before the request
- Shoulder pain is unresponsive to conservative treatment within the year before the request. Conservative treatment includes a documented trial of analgesics and physical therapy or chiropractic treatment.Within 1 year before the request
- Severe inframammary intertrigo: Persistent severe intertrigo in the inframammary fold is unresponsive to documented prescribed medication for at least three months within the year before the request.
Age-based mammogram requirement: For members aged 40 years or older, a negative screening mammogram has been obtained within two years of the planned reduction mammoplasty.Age 40 or older; within 2 years

Adolescent coverage criteria

Covered for adolescents ages 15 through 17 when all of the following criteria are met.

Adolescent clinical coverage

Age: The member is age 15 through 17.Age 15 through 17
Adult criteria incorporated
- Female member: The member is female.
- Clinical evaluation: A comprehensive medical history and complete physical examination, including a breast examination, have been conducted by the referring health care provider.

Case-by-case pediatric review

Requests for reduction mammoplasty for members under age 15 are considered individually.

Age: The member is under age 15.Under age 15
Individual review: The request is considered on a case-by-case basis.

Reduction mammoplasty is not covered for normal-sized breasts, defined as size C or smaller.

Reduction mammoplasty is not covered for surgically enlarged breasts with saline or silicone implants because these breasts are not considered breast hypertrophy, gigantomastia, or macromastia.

Clinical Thresholds and Documentation Timeframes

Breast size threshold

Covered breast sizeSize D or higher

Covered diagnosesBreast hypertrophy, gigantomastia, or macromastia

Noncovered breast sizeSize C or smaller

Conservative treatment timeframe

Required timeframeWithin 1 year before the request

Applicable symptomsBack pain, neck pain, or shoulder pain

Required conservative treatmentDocumented trial of analgesics and physical therapy or chiropractic treatment

Prior Authorization and Submission Requirements

Prior Authorization

Prior Authorization Required

MassHealth requires prior authorization (PA) for reduction mammoplasty. MassHealth reviews the request for medical necessity; approval does not by itself guarantee payment, which remains subject to member eligibility, other insurance, and all applicable program restrictions.

Prior Authorization

Submit the PA Request Correctly

Submit the PA request and all supporting documentation through the Provider Online Service Center (POSC), or complete the MassHealth PA-1 paper form and mail it with the documentation to the address on the form. Questions about POSC access may be directed to the MassHealth Customer Service Center at (800) 841-2900, TDD/TTY: 711.

Electronic submission: MassHealth Provider Online Service Center (POSC).
Paper submission: MassHealth Prior Authorization Request form (PA-1), available at www.mass.gov/masshealth.
Clinical information must be submitted by the MassHealth-enrolled qualified health professional performing the procedure.

Reduction Mammoplasty Overview

Reduction mammoplasty removes glandular, fatty, and skin tissue to treat symptomatic breast hypertrophy, including macromastia and gigantomastia. MassHealth considers coverage case by case when excessive breast tissue causes persistent symptoms that adversely affect health and conservative treatment has failed. The guideline focuses on functional and medical indications rather than cosmetic reduction.

Key Clinical Definitions

Breast hypertrophy

Tissue findingExcessive breast tissue

Related conditionsMacromastia, gigantomastia, or breast hypertrophy

Clinical impactPersistent clinical signs and symptoms that adversely affect health

Macromastia or gigantomastia

Covered size thresholdSize D or higher

Diagnostic terminologyMacromastia or gigantomastia, or breast hypertrophy

Normal-size threshold for noncoverageSize C or smaller

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Reduction Mammoplasty

Policy CodePolicy N/A

Change TypeRevisedno material clinical or coverage change

Effective DateMay 26, 2023

Next Review DateN/A

Key ActionSubmit the prior-authorization request and supporting documentation through the Provider Online Service Center or MassHealth PA-1 paper form.

SourceLink

On This Page

At least 3 months within 1 year before the request

Diagnosis and breast size:

The member has a diagnosis of breast hypertrophy, gigantomastia, or macromastia, with breast size D or higher.

Qualifying persistent symptom

Back pain is unresponsive to conservative treatment within the year before the request, including a documented trial of analgesics and physical therapy or chiropractic treatment.Within 1 year before the request
Neck pain is unresponsive to conservative treatment within the year before the request, including a documented trial of analgesics and physical therapy or chiropractic treatment.Within 1 year before the request
Shoulder pain is unresponsive to conservative treatment within the year before the request, including a documented trial of analgesics and physical therapy or chiropractic treatment.Within 1 year before the request
Severe inframammary intertrigo: Persistent severe intertrigo in the inframammary fold is unresponsive to documented prescribed medication for at least three months within the year before the request.At least 3 months within 1 year before the request

Surgical plan: The treating surgeon specifies the amount of tissue to be removed from each breast and the prognosis for improvement of symptoms related to breast hypertrophy, gigantomastia, or macromastia.

Exclusion of other causes: Other etiologies of the symptoms have been excluded.

Completed puberty: The member has completed puberty at Tanner stage V.Tanner stage V

Growth stabilization evidence

Height-visit evidence: The member has had at least a one-year history of growth stabilization evidenced by a minimum of four visits with documented heights.At least 1 year; minimum 4 visits
Radiographic evidence: Puberty completion is shown on a wrist radiograph read by a radiologist.Wrist radiograph

Intertrigo medication trial

ConditionPersistent severe inframammary intertrigo

TreatmentDocumented prescribed medication

Minimum durationAt least 3 months within 1 year before the request

Screening mammogram

Age thresholdMembers aged 40 years or older

Required resultNegative screening mammogram

TimingWithin 2 years of the planned reduction mammoplasty

Adolescent growth stabilization

Growth stabilization periodAt least 1 year

Visit-based evidenceMinimum of 4 visits with documented heights

Radiographic evidencePuberty completion shown on a wrist radiograph read by a radiologist

Documentation Required

Document Unsuccessful Conservative Pain Treatment

Document back, neck, or shoulder pain that remains unresponsive to conservative treatment during the year before the request. For each applicable symptom, the conservative-treatment trial must include analgesics and physical therapy or chiropractic treatment.

Identify the affected symptom: back pain, neck pain, and/or shoulder pain.
Document the analgesic trial and physical therapy or chiropractic treatment.
Include the treatment dates and evidence that symptoms remained unresponsive.

Documentation Required

Document Failed Intertrigo Treatment

For persistent severe intertrigo in the inframammary fold, document that prescribed medication was used for at least three months within the year before the request and that the condition remained unresponsive.

Document the diagnosis and severity of inframammary-fold intertrigo.
Identify the prescribed medication, treatment duration, and treatment failure.

Documentation Required

Provide Clinical History and Diagnoses

Provide a comprehensive medical history and physical examination, including a breast examination, and identify breast hypertrophy, gigantomastia, or macromastia as the primary cause of symptoms. Include relevant comorbid diagnoses and the member’s age at onset, condition duration, diagnosis date, current age, weight, height, and all previous breast surgeries.

Primary diagnosis: breast hypertrophy, gigantomastia, or macromastia (size D or higher).
Document comorbid conditions and evaluate other possible causes of the symptoms, including neurological symptoms when present.

Documentation Required

Document Prior Treatment History

Document all prior treatments used to manage symptoms and include progress notes showing symptoms, objective findings, assessment, and plan. Include any physical therapy, chiropractic treatment, analgesic use, and support-wear use for breast hypertrophy, gigantomastia, or macromastia during the preceding year.

Include treatment dates and response or lack of response.
Document prior treatment attempts in the clinical record and PA submission.

Documentation Required

Include Diagnostic and Photographic Evidence

Include pertinent diagnostic-test results and recent photographs confirming breast hypertrophy. Photographs must be front and lateral views from shoulder to waist and must have been taken within the last six months.

Provide diagnostic-test results relevant to the diagnosis.
Provide front and lateral shoulder-to-waist photographs taken within six months.

Documentation Required

Document the Surgical Treatment Plan

The treating surgeon must provide the definitive surgical treatment plan, including the amount of tissue planned for removal from each breast and the prognosis for improvement of symptoms related to breast hypertrophy, gigantomastia, or macromastia.

Specify planned tissue removal separately for each breast.
State the expected prognosis for improvement of the documented symptoms.

Documentation Required

Include Required Mammogram Results

For members aged 40 years or older, include the result of a screening mammogram performed within two years before the planned reduction mammoplasty.

Mammogram documentation is required for members aged 40 and older.
The mammogram must be within two years of the planned procedure.

Documentation Required

Document Adolescent Growth Stabilization

For adolescents aged 15 through 17, document at least one year of growth stabilization. This requires either a minimum of four visits with documented heights or evidence of completed puberty on a wrist radiograph read by a radiologist; completed puberty (Tanner stage V) is also required.

Document Tanner stage V or other evidence that puberty is complete.
Document four or more visits with recorded heights over at least one year, or puberty completion on a radiologist-read wrist radiograph.
Requests for members under age 15 are considered case by case.

Documentation Required

Support an Exception to Conservative Treatment

If the requesting provider concludes that physical therapy and/or chiropractic treatment will not improve the member’s pain, include a written clinical rationale supporting that conclusion with the PA request.

The written rationale should explain why physical therapy or chiropractic treatment is not expected to improve the pain.

Denial Risk

Check Excluded Breast Conditions

Reduction mammoplasty is not covered for normal-sized breasts or for surgically enlarged breasts with saline or silicone implants. Surgically enlarged breasts are not considered breast hypertrophy, gigantomastia, or macromastia under these guidelines.

Normal-sized breasts: American Society of Plastic Surgeons size C or smaller.
Surgically enlarged breasts with saline or silicone implants are excluded.

Denial Risk

Criteria Not Met May Result in Denial

Expect denial risk when the applicable coverage criteria are not all met or adequately documented. For adults, the record must support the required member and diagnosis criteria, an applicable unresponsive pain or intertrigo criterion, the surgical plan and prognosis, and exclusion of other symptom etiologies; for adolescents aged 15 through 17, the adult criteria plus completed puberty and at least one year of growth stabilization are required.

Adult criteria include female sex, comprehensive history and physical examination, breast hypertrophy/gigantomastia/macromastia, and at least one qualifying symptom-treatment criterion.
The qualifying symptom criterion is unresponsive back, neck, or shoulder pain after analgesics plus physical therapy or chiropractic treatment, or persistent severe intertrigo unresponsive to prescribed medication for at least three months within the preceding year.
Adolescents must also meet Tanner stage V and the required growth-stabilization documentation.

Denial Risk

Avoid an Incomplete or Improper PA Submission

Missing required clinical documentation or using an incorrect submission route can delay review or result in denial. Submit the complete supporting record through POSC or with the PA-1 form, including all required history, treatment, diagnostic, photographic, mammogram, adolescent-growth, and surgical-plan documentation applicable to the member.

Include all supporting documentation with the PA request.
Use POSC or the MassHealth PA-1 paper process; do not omit required attachments.
Include any other pertinent clinical information MassHealth requests.

Completed puberty

Puberty statusCompleted puberty

Tanner stageStage V

Applicable populationAdolescents aged 15 through 17 seeking reduction mammoplasty coverage