CurrentModa HealthPolicy N/A

Reduction Mammoplasty

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Coverage and prior authorization for reduction mammoplasty intended to relieve functional impairment from symptomatic macromastia in members age 16 or older or at Tanner stage V; cosmetic procedures and specified reconstructive or alternative procedures follow separate coverage pathways.

Policy Summary

PayerModa Health

PolicyReduction Mammoplasty

Policy CodePolicy N/A

Change TypeRoutine reviewno material change

Effective DateOct 1, 2026

Last ReviewSep 23, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit the required history and physical plus serial medical records establishing medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

19318Covered procedure code

2Non-covered procedure codes

16+ or Tanner VMinimum maturity

12 monthsQualifying pain duration

3 months

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CurrentModa HealthPolicy N/A

Reduction Mammoplasty

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Policy Summary

PayerModa Health

PolicyReduction Mammoplasty

Policy CodePolicy N/A

Change TypeRoutine reviewno material change

Effective DateOct 1, 2026

Last ReviewSep 23, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit the required history and physical plus serial medical records establishing medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

19318Covered procedure code

2Non-covered procedure codes

16+ or Tanner VMinimum maturity

12 monthsQualifying pain duration

3 months

Pain treatment trial

22% BSATissue removal threshold

Reduction Mammoplasty Coverage Criteria

Reduction mammoplasty coverage criteria

Covered to plan limitations when ALL of the following are met:

Reduction mammoplasty medical necessity

Age or physical maturity: The patient is at least 16 years old or is Tanner stage V.Age ≥16 or Tanner V
Weight stability: The patient's weight has not changed during the past two years or has stabilized.No weight change for 2 years or stabilized
Symptomatic macromastia
- Qualifying symptom pattern
  - Shoulder, neck, or back pain pathway
    Pain-supporting findings
    Failed conservative treatment: Conservative treatment, such as supportive devices or NSAIDs, failed for at least three months and is documented by serial chart notes.≥3 months
    Progressive pain: Pain increased in intensity over the documented period, supported by serial provider notes.Increasing intensity
    No alternative pain diagnosis: The pain is not associated with another diagnosis, including arthritis, disc disorders, or joint conditions.No other causal diagnosis
  - Severe intertrigo pathway: Severe intertrigo under the breasts remains unresponsive to at least six weeks of medical management, such as good hygiene, culture-specific topical antibiotics, or dressings, as documented in serial chart notes.Unresponsive after ≥6 weeks
Tissue-removal threshold: The requested amount of tissue removed from each breast is greater than or equal to 22% of body surface area, using the applicable body-surface-area/breast-weight table.≥22% BSA per breast
Use the Addendum I/Schnur sliding scale for the minimum grams per breast.
Cancer exclusion and screening: There is no evidence of breast cancer; for women over age 40, a mammogram was performed within one year of the proposed surgery.Mammogram within 1 year if over age 40
Procedure scope: The request is for covered reduction mammoplasty and not for surgical mastectomy, breast reduction, or liposuction for unilateral or bilateral gynecomastia, nor suction lipectomy or liposuction as a surgical alternative to reduction mammoplasty.Covered procedure scope
The policy identifies these excluded procedures as cosmetic or unproven for symptomatic macromastia.

BSA-based minimum tissue removal

The minimum breast tissue removal per breast is determined from the individual's BSA using the 22nd-percentile matrix.

BSA-based tissue removal threshold: Based on the individual's BSA, the 22nd percentile is the minimum breast tissue per breast that should be removed in order to be potentially considered medically necessary rather than cosmetic.Use the applicable BSA-to-gram matrix for each breast

Calculate BSA as the square root of [(height in inches × weight in pounds) ÷ 3,131]. Listed minimums per breast include: BSA 2.00 m² = 628 g; 2.05 = 687 g; 2.10 = 750 g; 2.15 = 819 g; 2.20 = 895 g; 2.25 = 978 g; 2.30 = 1,068 g; and 2.35 = 1,167 g.

Cosmetic reduction mammoplasty is not a covered benefit. Coverage under this policy is limited to reduction mammoplasty intended to relieve physical functional impairment when medical necessity is established.

Reduction mammoplasty performed as part of breast-cancer reconstruction is not evaluated under this policy. Refer those requests to the Moda Health Breast Reconstruction criteria.

Surgical mastectomy, breast reduction, or liposuction for unilateral or bilateral gynecomastia is considered cosmetic and is not covered under this policy.

Suction lipectomy or liposuction used as a surgical alternative to reduction mammoplasty is typically considered cosmetic and unproven for treating symptomatic macromastia.

Requests for reduction mammoplasty related to gender confirmation surgery should be evaluated under the MCG Gender Affirming Surgery or Procedure guidelines, GRG (GG-FMMF), rather than this policy.

This policy does not cover cosmetic reduction mammoplasty, procedures for unilateral or bilateral gynecomastia, or suction lipectomy/liposuction used as an alternative to reduction mammoplasty. Gynecomastia procedures are considered cosmetic, while the liposuction alternative is typically considered cosmetic and unproven for symptomatic macromastia. Breast-cancer reconstruction and gender confirmation surgery follow separate applicable criteria.

Coding and Clinical Thresholds

CPT or HCPCS codes coveredCPTCovered

19318

Reduction mammoplasty

CPT or HCPCS codes NOT coveredCPTNot Covered

15877	Suction assisted lipectomy; trunk
19300	Mastectomy for gynecomastia

Applicable ICD-10 diagnosis codesICD-10

N62	Hypertrophy of breast
M25.511-M25.519	Pain in shoulder

Member age or physical maturity

Age requirementAt least 16 years old

Physical-maturity alternativeTanner stage V

ApplicationThe patient must meet the age or physical-maturity requirement for coverage consideration.

Weight stability

Two-year historyWeight has not changed during the past two years

AlternativeWeight has stabilized

Documentation

Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for reduction mammoplasty. Submit clinical records establishing that the member meets the medical-necessity criteria and include the supporting documentation listed below.

The request must document eligibility, symptomatic macromastia, functional impairment, treatment history, and the planned amount of tissue removal.

Step Therapy

Conservative Treatment Before Surgery

Before surgery, document failed conservative treatment for qualifying pain for at least 3 months. Include serial chart notes showing the treatment provided and the patient's response; examples include supportive devices and NSAIDs.

For pain attributed to macromastia, document pain lasting at least 12 months and failed conservative treatment for at least 3 months.
If severe intertrigo is the qualifying symptom, document that it remained unresponsive to at least 6 weeks of medical management, such as good hygiene, culture-specific topical antibiotics, or dressings, in serial chart notes.

Policy Background

Reduction mammoplasty is the surgical excision of a substantial portion of breast tissue, including the skin and underlying glandular tissue, to reduce breast size, change breast shape, and/or lift the breasts. Under this policy, the procedure may be approved individually when medical necessity is established to relieve physical functional impairment associated with symptomatic macromastia.

Definitions and Maturity Assessment

Reduction mammoplasty

ProcedureSurgical excision of a substantial portion of the breast

Tissue removedThe excision includes skin and underlying glandular tissue.

Intended effectThe procedure reduces breast size and may change breast shape and/or lift breast tissue.

Macromastia

ConditionExcessive breast size

Required associationDocumented physical symptoms or functional impairment

ExamplesQualifying pain, neurologic symptoms, severe headaches, or severe intertrigo

Policy Summary

PayerModa Health

PolicyReduction Mammoplasty

Policy CodePolicy N/A

Change TypeRoutine reviewno material change

Effective DateOct 1, 2026

Last ReviewSep 23, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit the required history and physical plus serial medical records establishing medical necessity.

SourceLink

On This Page

Associated neurologic or headache symptoms: Related arm numbness or weakness consistent with brachial plexus compression syndrome, or severe occipital headaches associated with neck and upper-back pain with cervical spine x-rays showing no other cause, is documented.At least 1 associated symptom pattern

Weight stability or stabilization must be documented in the medical record.

Qualifying pain duration

Minimum durationAt least 12 months

Qualifying symptomsShoulder, neck, or back pain, or related neurologic or severe headache symptoms

Functional impactSymptoms must be attributable to macromastia and affect daily activities.

Conservative treatment for pain

Minimum treatment periodAt least 3 months

Supportive devicesSupportive devices are an example of conservative treatment.

MedicationNSAIDs are an example of conservative treatment.

RecordsFailure of treatment must be documented by serial chart notes.

Minimum tissue removal

Minimum removalGreater than or equal to 22% of body surface area per breast

Measurement basisThe threshold is based on the individual's body surface area.

ApplicationThe applicable BSA-to-breast-weight table determines the minimum tissue removal per breast.

Intertrigo medical management

Minimum management periodAt least 6 weeks

ConditionSevere intertrigo, meaning chafing under the breasts

Examples of managementGood hygiene, culture-specific topical antibiotics, or dressings

Required responseThe condition must remain unresponsive to medical management and be documented in serial chart notes.

Mammography

Age criterionWomen over age 40

TimingWithin 1 year before the proposed surgery

Required screeningA mammogram must have been performed, and there must be no evidence of breast cancer.

Schnur sliding scale examples

BSA 1.35 m²199 g per breast

BSA 1.40 m²218 g per breast

BSA 1.45 m²238 g per breast

BSA 1.50 m²260 g per breast

BSA 1.55 m²284 g per breast

BSA 1.60 m²310 g per breast

BSA 1.65 m²338 g per breast

22nd-percentile minimum breast tissue removal per breast by BSA

BSA 2.00–2.05 m²628–687 g per breast

BSA 2.10–2.15 m²750–819 g per breast

BSA 2.20–2.25 m²895–978 g per breast

BSA 2.30–2.35 m²1,068–1,167 g per breast

Documentation Required

Required Prior Authorization Records

Submit a history and physical with the measurements and maturity assessment required for review, together with records that substantiate the reported symptoms and prior treatment.

Patient height, weight, and approximate grams of tissue to be removed from each breast.
Tanner stage of sexual maturity when the patient is an adolescent.
Serial chart notes documenting conservative treatment, persistent symptoms for 12 months, and how symptoms interfere with activities of daily living.
Chart notes from a physician other than the surgeon documenting prior treatment and visits for macromastia.

Documentation Required

Medical Necessity Documentation

Document medical necessity for symptomatic macromastia rather than cosmetic surgery. The record should show stable weight, qualifying symptoms, duration, functional impact, and appropriate treatment history.

Patient is at least 16 years old and/or has reached Tanner stage V, and weight has not changed during the past 2 years or has stabilized.
Macromastia causes at least one qualifying condition affecting daily activities: shoulder, neck, or back pain for at least 12 months; related arm numbness or weakness consistent with brachial plexus compression; severe occipital headaches associated with neck and upper-back pain when cervical-spine X-rays show no other cause; or severe intertrigo meeting the treatment requirement.
For qualifying pain, document at least two supporting elements: failed conservative treatment for at least 3 months, increasing pain intensity documented in serial provider notes, and absence of another cause such as arthritis, disc disorder, or joint condition.
Document that the requested tissue removal from each breast is at least 22% of body surface area (BSA) under the Schnur Sliding Scale.

Documentation Required

Mammography Documentation

For women over age 40, document that a mammogram was performed within 1 year before the proposed surgery and that there is no evidence of breast cancer.

Include the mammography report or other record verifying the date and result when applicable.

Documentation Required

Document Tanner Stage Assessment

For an adolescent, include a completed Tanner stage assessment with the documentation needed to identify and authenticate the assessment.

Patient name and age/date of birth.
Tanner level.
Physician name and physician signature.
The member must meet the applicable maturity requirement, including Tanner stage V when used to establish eligibility.

Denial Risk

Common Denial Risks

Requests may be denied when the documentation does not establish functional medical necessity or when the request falls within an excluded cosmetic service.

Cosmetic intent or a request without physical functional impairment is not covered.
Missing documentation of symptoms affecting activities of daily living, symptom duration, stable weight, conservative treatment, or prior treatment visits creates a denial risk.
Pain must meet the duration and supporting-documentation requirements and must not be attributable to another diagnosis.
The requested tissue removal must meet the 22% of BSA threshold for each breast, and the member must meet the age or maturity requirement.
Mastectomy, breast reduction, or liposuction for gynecomastia is considered cosmetic under this policy; suction lipectomy/liposuction as an alternative to reduction mammoplasty is typically cosmetic and unproven for symptomatic macromastia.

Note

Gender Confirmation Surgery

If the reduction mammoplasty request is related to gender confirmation surgery, refer the request to the MCG Gender Affirming Surgery or Procedure GRG (GG-FMMF) criteria.

Do not apply this reduction mammoplasty pathway as the governing criteria for a gender confirmation surgery request.

Severe intertrigo

LocationChafing or inflammation beneath the breasts

PersistenceRemains unresponsive to medical management

Minimum management periodAt least 6 weeks

Tanner stage V

Maturity levelTanner stage V

Coverage rolePhysical-maturity alternative to the age requirement

Related criterionThe policy states coverage may be considered for members at least 16 years old or who have reached physical maturity.

Body Surface Area (BSA)

UnitMeters squared (m²)

Step 1Multiply height in inches by weight in pounds.

Step 2Divide the result by 3,131.

Step 3Take the square root of the result to obtain BSA in meters squared.

Tanner Stage I

Breast developmentPre-adolescent

Pubic hairNone

Other changesPre-adolescent findings

Tanner Stage II

Breast developmentBreast budding with areolar hyperplasia and a small amount of breast tissue

Pubic hairLong, downy pubic hair near the labia may appear

Other changesPeak growth velocity often occurs soon after stage II.

Tanner Stage III

Breast developmentFurther enlargement of breast tissue and areola without separation of their contours

Pubic hairAdult in type but not in distribution

Other changesMenarche occurs in approximately 2% of girls late in stage III.

Tanner Stage IV

Breast developmentSeparation of breast contours

Areola and nippleForm a secondary mound above the breast tissue

Pubic hairAdult in type but not in distribution

Tanner Stage V

Breast developmentLarge adult breast with a single contour

Pubic hairAdult in distribution

Other changesMenarche occurs in approximately 10% of girls in stage V.