CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Breast Reduction Prior Authorization Form / Coverage Criteria

Form and requirements for requesting prior authorization for breast reduction surgery for Neighborhood Health Plan of Rhode Island members; used by providers to submit clinical and administrative information required for authorization review.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyBreast Reduction Prior Authorization Form / Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed Breast Reduction Prior Authorization Form with required clinical documentation, physician signature, dates of ≥6 weeks of conservative treatment, and mammogram (for women >40).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 weeksconservative treatment duration

1 yearmammogram recency (>40)

requiredphysician signature

Coverage Criteria for Breast Reduction Prior Authorization

Information required for authorization review

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Required form elements: Member and provider identification; CPT and diagnosis codes; description of symptoms including presence or absence of well-defined shoulder grooving and other musculoskeletal conditions (location and character of pain); documentation of medical/conservative treatment received for persistent neck, back, shoulder or other musculoskeletal symptoms attributed to large breasts with start and end dates (at least 6 weeks); estimated tissue removal per breast; documentation whether counseling regarding breastfeeding occurred and comments on future breastfeeding plans; for women >40, a mammogram within one year with report documenting no evidence of breast cancer; treating physician signature and date.

All fields provided on the prior authorization form are used to assess medical necessity.

Coding and Related Clinical Timelines

Requested codes (fill-in fields)mixed

CPT Code	Field on form — specific CPT codes to be entered by provider
Diagnosis Code	Field on form — specific ICD-10 diagnosis code to be entered by provider

Conservative treatment duration

Minimum documented conservative treatment durationAt least 6 weeks of documented nonoperative/medical treatment with start and end dates

Treatment dates requiredProvide specific start and end dates for the conservative therapy period

Symptom attributionTreatment must address persistent neck, back, shoulder, or other musculoskeletal symptoms attributed to large breasts

Mammogram requirement for women over 40

Mammogram recency requirementFor women >40, a mammogram completed within 1 year of surgery must be submitted

Purpose of mammogramReport must document no evidence of breast cancer

Attach with requestSubmit the mammogram report with the prior authorization request

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required — submit the completed Breast Reduction Prior Authorization Form to Neighborhood Health Plan of Rhode Island Utilization Management.

Return completed form to Utilization Management at (401) 459-6023.
Include member and provider information, CPT and diagnosis codes, symptom description, dates of conservative therapy, and supporting documentation.
For women > age 40, include a mammogram completed within one year with report documenting no evidence of breast cancer.

Documentation Required

Conservative Therapy Documentation

Document at least 6 weeks of conservative/medical therapy for musculoskeletal symptoms attributed to large breasts. Provide start and end dates for the conservative treatment period and describe treatments attempted (e.g., physical therapy, analgesics, supportive garments).

Dates of treatment (must cover at least 6 weeks) — include Start and End dates.
Describe medical treatment received for persistent neck, back, shoulder or other musculoskeletal pain attributed to large breasts.
Indicate presence or absence of well-defined shoulder grooving and other related findings.

Documentation Required

Required Documentation

Submit a completed prior authorization form with all required clinical information and supporting documentation.

Completed Breast Reduction Prior Authorization Form signed by the treating physician.
Member and provider information, CPT code(s), diagnosis and diagnosis code(s).
Detailed symptom description, estimated tissue removal per breast, and counseling about future breastfeeding documented.
Mammogram report for women >40 as noted above.

Denial Risk

Authorization Decision Note

An authorization decision is not a guarantee of payment. If the request is not approved, a Not Approved letter will be sent to the provider.

Authorization number, dates of service, approval status, UM initials, and notification date will be provided on the decision.
Not Approved Letter to follow if authorization is denied.

Background

The prior authorization form requests clinical details to document medical necessity for breast reduction, including: description of symptoms (with presence or absence of well-defined shoulder grooving), locations and other musculoskeletal conditions, documentation of prior medical/nonoperative treatment with start and end dates (at least 6 weeks), estimated tissue removal per breast, counseling about breastfeeding, and for women >40 a recent mammogram report showing no evidence of breast cancer. CPT and diagnosis code fields and provider/member identification must also be completed.

Definitions

Conservative treatment (definition)

Definition of conservative treatmentNonoperative medical treatment for persistent neck, back, shoulder or other musculoskeletal symptoms attributed to large breasts

Documentation standardConservative treatment must be documented with start and end dates (minimum 6 weeks)

Scope of symptomsIncludes shoulder grooving, neck/back pain, and other musculoskeletal conditions related to breast size