CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Reduction Mammoplasty

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This guideline identifies the clinical information MassHealth needs to determine medical necessity and prior-authorization eligibility for reduction mammoplasty in members with symptomatic breast hypertrophy, macromastia, or gigantomastia. It applies to MassHealth providers and requires case-by-case review, subject to general MassHealth eligibility, insurance, program, and service conditions.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Reduction Mammoplasty

Policy CodePolicy N/A

Change TypeRevision — no material clinical or coverage change

Effective DateMay 26, 2023

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

RequiredPrior authorization

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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 TypeRevision — no material clinical or coverage change

Effective DateMay 26, 2023

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

RequiredPrior authorization

15–17Adolescent coverage

40+Mammogram age threshold

6 monthsPhoto age limit

C or smallerExcluded breast size

Clinical Coverage Criteria

Members under age 15

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

Case-by-case review: A request for reduction mammoplasty for a member under age 15 will be considered on a case-by-case basis.Under age 15

No fixed clinical criteria are specified for this age group.

Reduction mammoplasty clinical criteria

The clinical coverage criteria in Section II.A.1(a through f) must be met.

Section II.A.1 clinical criteria

Member eligibility: The member is female.Required
Section II.A.1.1.
Back pain and conservative treatment: 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
Analgesics and physical therapy or chiropractic treatment are required components.
Surgeon documentation: 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.Amount specified for each breast
Section II.A.1.5.
Remaining applicable criteria: The remaining applicable criteria in Section II.A.1(a through f) must also be satisfied.Required
The cited excerpt does not reproduce each remaining subcriterion.

Reduction mammoplasty is not covered for normal-sized breasts, defined by the American Society of Plastic Surgeons as size C or smaller.

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

Clinical Thresholds and Documentation Parameters

Adult qualifying breast size

Adult eligibilityClinical coverage applies to individuals aged 18 and over.

Qualifying diagnosisBreast hypertrophy, gigantomastia, or macromastia.

Qualifying breast sizeSize D or higher.

Neck or shoulder conservative treatment period

Qualifying symptomsNeck pain or shoulder pain unresponsive to conservative treatment.

Treatment timeframeTreatment must occur within the year before the request.

Required treatment components

Prior Authorization and Submission Requirements

Prior Authorization

Prior Authorization Required

MassHealth requires prior authorization (PA) for reduction mammoplasty. The PA request and supporting clinical documentation must be submitted by the MassHealth-enrolled qualified health professional performing the procedure, through the Provider Online Service Center (POSC) or the PA-1 paper form.

Providers are strongly encouraged to submit requests electronically through POSC.
For paper submission, complete the MassHealth PA-1 form, attach all supporting documentation, and mail it to the address on the back of the form.

Billing Rule

Approval Is Not a Payment Guarantee

PA approval is not a guarantee of payment. Payment remains subject to all general MassHealth conditions, including member eligibility, other insurance, and program restrictions.

Reduction Mammoplasty Overview

Reduction mammoplasty removes glandular, fatty, and skin tissue from the breast to alleviate or correct medical problems caused by excessive breast tissue. It is used to treat symptomatic breast hypertrophy, including macromastia and gigantomastia, when excessive breast tissue causes persistent clinical signs and symptoms that adversely affect health.

Key Definitions

Reduction mammoplasty

ProcedureReduction mammoplasty.

Tissue removedGlandular, fatty, and skin tissue from the breast.

PurposeTo alleviate or correct medical problems caused by excessive breast tissue.

Breast hypertrophy, macromastia, or gigantomastia

ConditionExcessive breast tissue presenting as breast hypertrophy.

Related termsMacromastia or gigantomastia.

Adult qualifying descriptionThe guideline identifies size D or higher as qualifying for the stated adult diagnosis criterion.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Reduction Mammoplasty

Policy CodePolicy N/A

Change TypeRevision — no material clinical or coverage change

Effective DateMay 26, 2023

Next Review DateN/A

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

SourceLink

On This Page

A documented trial of analgesics and physical therapy or chiropractic treatment.

Persistent severe intertrigo medication period

ConditionPersistent severe intertrigo in the inframammary fold.

Treatment responseUnresponsive to documented prescribed medication.

Required medication periodAt least three months within the year before the request.

Screening mammogram

Applicable ageMembers aged 40 and older.

Mammogram resultNegative screening mammogram.

Required timeframeWithin two years of the planned reduction mammoplasty.

Adolescent growth stabilization

Applicable age rangeAdolescents aged 15 through 17.

Growth stabilization periodAt least one year.

Acceptable documentationA minimum of four visits with documented heights, or puberty completion shown on a wrist radiograph read by a radiologist.

Photo documentation

Documentation agePhotographs must be taken within the last six months.

Required viewsFront and lateral views.

Field of viewEach view must extend from shoulder to waist and confirm breast hypertrophy.

Documentation Required

Conservative Treatment for Neck or Shoulder Pain

For neck or shoulder pain, document that symptoms were unresponsive to conservative treatment within the year before the PA request.

The conservative-treatment trial must include documented analgesic use.
The trial must also include physical therapy or chiropractic treatment.

Documentation Required

Medical Treatment for Intertrigo

Document persistent severe intertrigo in the inframammary fold that was unresponsive to prescribed medication treatment for at least three months within the year before the PA request.

Include documentation of the prescribed medication and the treatment duration.

Documentation Required

Exception to Therapy Trial

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

Documentation Required

History, Examination, and Diagnoses

Submit documentation establishing the member’s clinical presentation and the cause of symptoms.

Primary diagnosis: breast hypertrophy, gigantomastia, or macromastia as the cause of symptoms.
Diagnoses of co-morbid conditions.
Most recent medical evaluation, including medical history and complete physical examination, including the breasts.
Document age at onset, duration of the condition, diagnosis date, current age, weight, height, co-morbid conditions, and all previous breast surgeries.

Documentation Required

Prior Conservative Treatment

Document the member’s prior treatment for symptoms and include progress notes supporting the treatment history.

Progress notes must detail symptoms, objective findings, assessment, and plan.
Include physical therapy, chiropractic treatment, analgesic use, and support-wear use for breast hypertrophy, gigantomastia, or macromastia within the last year.

Documentation Required

Diagnostic, Photographic, and Surgical-Plan Documentation

Include the clinical documentation needed to confirm the diagnosis and support the planned reduction mammoplasty.

Results of diagnostic tests pertinent to the diagnosis.
Photographs taken within the last six months showing the member from the front and lateral shoulder to waist, confirming breast hypertrophy.
A definitive surgical treatment plan specifying the amount of tissue to be removed from each breast and the prognosis for symptom improvement.

Documentation Required

Evaluate Alternative Etiologies and Neurological Symptoms

Evaluate and rule out other co-morbid etiologies of the symptoms. The evaluation must address any neurological symptoms that are present.

Include imaging when appropriate.
Document the evaluation and exclusion of alternative causes of the member’s symptoms.

Documentation Required

Age-Specific Documentation

Include age-specific documentation with the PA request.

For members aged 40 or older, provide a negative screening mammogram performed within two years of the planned reduction mammoplasty.
For adolescents aged 15 through 17, document at least one year of growth stabilization, evidenced by either a minimum of four visits with documented heights or completion of puberty shown on a wrist radiograph read by a radiologist.
For adolescents, document completion of puberty at Tanner stage V.

Note

Additional Information

MassHealth may request other pertinent clinical information needed to evaluate medical necessity. Be prepared to provide any additional information requested.

Documentation Required

Document Conservative Treatment for Back Pain

For back pain, document that symptoms were unresponsive to conservative treatment within the year before the PA request.

The conservative-treatment history must include a documented trial of analgesics.
It must also include physical therapy or chiropractic treatment.

Documentation Required

Provide Surgical Estimate and Prognosis

The treating surgeon must provide a definitive surgical treatment plan supporting the expected clinical benefit.

Specify the amount of tissue to be removed from each breast separately.
State the prognosis for improvement of symptoms related to breast hypertrophy, gigantomastia, or macromastia.

Denial Risk

Normal-Sized Breasts Are Not Covered

Reduction mammoplasty is not covered for normal-sized breasts as described by the American Society of Plastic Surgeons.

Breasts of size C or smaller are excluded from coverage.

Denial Risk

Implant-Enlarged Breasts Are Not Covered

Reduction mammoplasty is not covered when the breasts were surgically enlarged with saline or silicone implants.

Surgically enlarged breasts are not considered breast hypertrophy, gigantomastia, or macromastia.

Denial Risk

Adult Criteria Must Be Established

For adults aged 18 and older, reduction mammoplasty may be medically necessary only when all applicable adult medical-necessity criteria are established. Requests that do not establish the required criteria are at risk for denial.

The member must be female.
The member must have breast hypertrophy, gigantomastia, or macromastia, with the condition causing symptoms.
The required history, physical examination, symptom-specific conservative treatment, exclusion of other etiologies, and age-specific documentation must be provided as applicable.

Note

Member Younger Than 15

Requests for reduction mammoplasty for members younger than 15 are not evaluated under the stated adolescent criteria. They will be considered on a case-by-case basis.

Denial Risk

Failure to Meet Clinical Criteria

A request may be denied when the member, symptom, treatment, or clinical documentation requirements are not met or cannot be established.

Failure to establish the applicable member and age criteria.
Failure to document qualifying symptoms and unresponsive conservative treatment.
Failure to provide the required diagnoses, examination, history, test results, photographs, surgical plan, prognosis, and evaluation of alternative etiologies.
Reduction mammoplasty is not covered for normal-sized breasts or surgically enlarged breasts with saline or silicone implants.

Tanner stage V

StageThe fifth Tanner stage.

Clinical meaningIndicates completed puberty.

ApplicationUsed as evidence of completed puberty in the adolescent reduction mammoplasty criteria.