CurrentMississippi Division of MedicaidPolicy N/A

Reduction Mammoplasty (breast reduction) Coverage Criteria

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Defines medical necessity, clinical criteria, and documentation requirements for coverage of reduction mammoplasty under Mississippi Division of Medicaid; applies to providers submitting claims for beneficiaries seeking reduction mammoplasty.

Policy Summary

PayerMississippi Division of Medicaid

PolicyReduction Mammoplasty (breast reduction) Coverage Criteria

Policy CodePolicy N/A

Change TypeRevised effective date and administrative update

Effective DateMay 1, 2026

Last ReviewMay 1, 2026

Next Review DateN/A

Key ActionSurgeon must retain complete medical record documentation demonstrating medical necessity, including 2 years of symptoms, minimum tissue removal (typically ≥500 g per breast), and suprasternal notch-to-nipple measurement ≥28 cm.

SourceLink

POLICY UPDATE CHANGES

Rule language revised effective 05/01/2026 (History shows revision effective 05/01/2026).

≥500 gmin tissue removal (per breast)

≥28 cmsn-n distance

2 yearsrequired symptom duration

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CurrentMississippi Division of MedicaidPolicy N/A

Reduction Mammoplasty (breast reduction) Coverage Criteria

Customize your policy alerts

Sign up for all Mississippi Division of Medicaid policy alerts

Know when Mississippi Division of Medicaid releases new policies or updates existing guidance.

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Policy Summary

PayerMississippi Division of Medicaid

PolicyReduction Mammoplasty (breast reduction) Coverage Criteria

Policy CodePolicy N/A

Change TypeRevised effective date and administrative update

Effective DateMay 1, 2026

Last ReviewMay 1, 2026

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

Rule language revised effective 05/01/2026 (History shows revision effective 05/01/2026).

≥500 gmin tissue removal (per breast)

≥28 cmsn-n distance

2 yearsrequired symptom duration

age / sexual maturity (<18)

Coverage criteria for reduction mammoplasty

Covered when ALL of the following are met:

Primary coverage requirements: Procedure is medically necessary; reconstructive; performed as a last means to alleviate symptoms/dysfunction due to excessive breast size

From Rule 4.18.A

Documentation for beneficiaries under 18: If under 18: evaluated by primary care provider; PCP documents appropriateness; beneficiary is ≥16 years and Tanner Stage V; PCP agrees beneficiary is appropriate for surgical evaluation

From Rule 4.18.B

Surgeon documentation requirements: Complete history including complaints of pain and restriction of normal activity for past 2 years; medical necessity for removal of a minimum of 500 grams of tissue from each breast (or full documentation justifying removal <500 g); suprasternal notch-to-nipple measurement ≥28 cm

From Rule 4.18.C

Reduction mammoplasty is covered only when the surgeon documents that the procedure is medically necessary, has a reconstructive intent, and is being performed as a last means to alleviate symptoms and dysfunction caused by excessive breast size. The rule requires objective and historical documentation to support medical necessity, including specific anatomic measurements, minimum tissue removal thresholds, and a prolonged history of symptoms.

Procedures will not meet medical necessity if the medical record lacks the required documentation. Examples of missing or insufficient documentation include: no history showing complaints of pain and restriction of normal activity for the past 2 years; absent or undocumented suprasternal notch-to-nipple measurement of ≥ 28 cm; missing documentation that at least 500 grams of tissue per breast will be removed (or an explicit, justified explanation in the record when less tissue is removed); lack of primary care provider evaluation and documentation for beneficiaries under 18 (including confirmation of age ≥ 16 and Tanner Stage V where applicable); and failure to retain supporting findings such as intertrigo, deep bra strap grooves, or a psychological assessment.

Key clinical thresholds and coding-relevant measurements

Minimum tissue removal per breast — 500 grams

Minimum tissue removal per breastMinimum of 500 grams of tissue must be removed from each breast; if less than 500 grams removed, surgeon must fully document justification in the medical record.

Documentation when <500 g removedSurgeon must provide full documentation in the medical record justifying reduction with removal of less than 500 grams per breast.

Relation to medical necessityRemoval amount is required to demonstrate medical necessity for reconstructive reduction mammoplasty.

Suprasternal notch-to-nipple distance threshold — 28 cm

Suprasternal notch-to-nipple distanceSupra sternal notch to nipple measurement of 28 cm or greater is required.

Purpose of measurement

Documentation, prior authorization, and provider responsibilities

Prior Authorization

Prior authorization / documentation requirement

Prior authorization is not explicitly specified in the rule text; however, providers must document medical necessity and retain supporting records to establish coverage eligibility for reduction mammoplasty.

Step Therapy

Surgery must be last means to relieve symptoms

The procedure must be performed only as a last means to attempt to alleviate symptomatology and dysfunction due to excessive breast size; less invasive measures should have been attempted before surgery is considered.

Documentation Required

Background and scope

Reduction mammoplasty is intended to relieve symptomatic macromastia when conservative measures have failed. The policy emphasizes that coverage is contingent on both clinical and reconstructive justification: a complete history documenting complaints of pain and restriction of normal activity for at least 2 years; objective measurements including a suprasternal notch‑to‑nipple distance of ≥ 28 cm; and documentation that removal of a minimum of 500 grams of tissue from each breast is medically necessary (or that the surgeon has fully documented the clinical rationale if less tissue is removed). For beneficiaries under 18, the primary care provider must have evaluated and documented appropriateness for surgical evaluation and confirmed the beneficiary is at least 16 years of age and at Tanner Stage V. The surgeon must retain all supporting documentation in the medical record.

Clinical definitions used in policy

Macromastia — clinically symptomatic excessive breast size causing pain and activity restriction

DefinitionClinically symptomatic excessive breast size causing pain and restriction of normal activity.

Clinical justificationDiagnosis is justified based on the probability of relieving clinical signs and symptoms with reduction mammoplasty.

Supporting findingsDocumentation such as intertrigo, deep bra strap grooves, or psychological assessment may support the determination of medical necessity.

Reconstructive intent — procedure performed to alleviate symptomatology and dysfunction due to excessive breast size

DefinitionProcedure performed to alleviate symptomatology and dysfunction due to excessive breast size.

Coverage context

Policy Summary

PayerMississippi Division of Medicaid

PolicyReduction Mammoplasty (breast reduction) Coverage Criteria

Policy CodePolicy N/A

Change TypeRevised effective date and administrative update

Effective DateMay 1, 2026

Last ReviewMay 1, 2026

Next Review DateN/A

SourceLink

On This Page

Measurement is an objective anatomic threshold used to support probability of relieving signs and symptoms of macromastia.

DocumentationSurgeon must include the measurement in the medical record to support medical necessity.

Required symptom duration — 2 years

Required symptom durationComplete history must include complaints of pain and restriction of normal activity for the past 2 years.

Role in justificationLong‑standing symptoms (≥2 years) support the probability that reduction will relieve clinical signs and symptoms of macromastia.

Record retentionSurgeon must retain documentation of the 2‑year history in the medical record.

Age/sexual maturity for minors — Age ≥16 and Tanner Stage V

Minimum age for minorsBeneficiaries under 18 must be at least 16 years of age to meet coverage criteria.

Sexual maturity requirementBeneficiaries under 18 must have reached Tanner Stage V of the Tanner Staging of Sexual Maturity Rating.

Combined requirement (most actionable)If beneficiary is under 18, the primary care provider must document that the beneficiary is ≥16 years AND Tanner Stage V before surgical evaluation can be considered.

Retain complete surgical and justification records

The surgeon must retain a complete medical record showing medical necessity, including a history of pain and restriction of normal activity for the past two years, measurements (suprasternal notch-to-nipple ≥ 28 cm), and documentation of tissue removal (minimum 500 grams per breast or full justification if less).

History documenting pain and restriction of normal activity for the past two (2) years
Suprasternal notch-to-nipple measurement ≥ 28 cm
Documentation of removal of at least 500 grams of tissue from each breast, or full justification in the record if less

Denial Risk

Denial risk for insufficient documentation

Claims may be denied if the medical record fails to demonstrate medical necessity, reconstructive intent, exhaustion of less invasive measures, or required measurements and tissue weights.

Missing history of ≥2 years of pain/restriction
No suprasternal notch-to-nipple measurement ≥28 cm documented
No documentation of ≥500 g tissue removal per breast or justification for less
No documentation that the procedure is reconstructive and a last means to relieve symptoms

Reduction mammoplasty must be reconstructive and performed as a last means to alleviate symptoms/dysfunction from excessive breast size to be covered.

Documentation requirementSurgeon and primary care provider documentation must demonstrate reconstructive intent and that less invasive measures were attempted or considered.