CurrentPartners Health ManagementPolicy NC.CP.MP.501

Breast Surgeries

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Medical necessity criteria and coverage guidance for breast surgeries including mastectomy/breast conserving surgery, male gynecomastia surgery, prophylactic mastectomy, reduction mammoplasty, and breast reconstruction for Partners Health Management members.

Policy Summary

PayerPartners Health Management

PolicyBreast Surgeries

Policy CodePolicy NC.CP.MP.501

Change TypeNo material changes

Effective Date

Last ReviewFeb 1, 2026

Next Review DateFeb 1, 2026

Key ActionObtain prior authorization and submit required clinical documentation including height/weight, unclothed pre-op photos, objective findings, and evidence of conservative therapy when applicable.

SourceLink

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CurrentPartners Health ManagementPolicy NC.CP.MP.501

Breast Surgeries

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Policy Summary

PayerPartners Health Management

PolicyBreast Surgeries

Policy CodePolicy NC.CP.MP.501

Change TypeNo material changes

Effective Date

Last ReviewFeb 1, 2026

Next Review DateFeb 1, 2026

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleprocedure types governed

BMI ≤ 30gynecomastia BMI threshold

≥18/Tanner Vage/Tanner threshold

BSA/SchnurSchnur sliding scale used

Not coveredcosmetic procedures

Extensivesupporting references

Coverage Criteria for Breast Procedures

Mastectomy for male gynecomastia

Covered when ALL of the following are met:

Gynecomastia surgical indication: A. One of: an adult member has gynecomastia persisting >3 months after pathological causes are ruled out OR an adolescent has gynecomastia persisting >6 months after pathological causes are ruled out; B. Excessive tissue is glandular (confirmed by clinical exam AND either ultrasound or mammogram); C. Other causes (obesity, adolescence, drug treatments) have been ruled out; D. Excessive tissue is not caused by medications, non-covered therapies, alcohol, or illicit drugs (exception: psychotropic medication may be allowed if prescribing physician documents it cannot be discontinued); E. Member BMI ≤ 30 OR has participated in a clinically supervised weight loss and exercise program ≥6 consecutive months; F. Documented history of significant medical symptoms due to gynecomastia not resolved by conservative treatments; G. Required medical documentation submitted: height, weight, age; unclothed pre-operative photos (chin to waist frontal and side); objective signs/symptoms and duration; prior management and current medications; endocrine study results; confirmation glandular tissue; and a list of subjective symptoms with supporting documentation.

Prophylactic mastectomy

Covered when ALL of the following apply:

Prophylactic mastectomy: A. One of: (1) Any one of: a) breast biopsy shows high risk (atypical hyperplasia or LCIS); b) personal history of breast cancer in contralateral breast; c) positive BRCA1 or BRCA2 genetic testing; d) personal history of contralateral breast cancer in a pre-menopausal woman; OR (2) Two or more of: a) family history strongly suggestive of an autosomal dominant hereditary mutation predisposing to breast/ovarian cancer; b) immediate family history of breast cancer (mother, sister, daughter, brother, father); c) personal history of ovarian cancer or first-degree relative with ovarian cancer; d) severe benign disease interfering with mammogram interpretation or extensive mammographic abnormalities where adequate biopsy/excision is impossible; AND B. Documentation submitted: history and physical, diagnoses, medical records demonstrating the above criteria, and a plan of treatment including any planned reconstruction.

Unilateral reduction mammoplasty

Covered when ALL of the following are met:

Unilateral reduction mammoplasty is covered when performed for congenital absence or loss of significant female breast tissue of the contralateral breast subsequent to trauma or medically necessary mastectomy (including for cancer or high cancer risk).

Reduction mammoplasty (macromastia)

Covered when ALL of the following are met (A OR B subgroup — A shown here):

Reduction mammoplasty (A: Macromastia): 1) Member is ≥18 years OR if <18: Tanner stage V AND no breast growth (change in cup size) for ≥6 months; 2) Estimated tissue to be removed meets the minimum weight requirement based on member's BSA per the Schnur Sliding Scale (Appendix B); 3) Member has at least two of the following symptoms affecting activities of daily living: headaches with neck/upper back pain; neck/shoulder/arm/upper back pain not due to other causes; breast pain from excessive tissue; painful kyphosis documented by X-ray; bra strap grooving/ulceration; paresthesia from brachial plexus compression; inframammary intertrigo; or significant activity restriction; 4) Physician documents ALL of the following: a) pain unresponsive to conservative treatment with evidence of at least two therapeutic measures (NSAIDs; physical therapy/exercise when skeletal pathology present; supportive devices such as proper bra support; medically supervised weight loss program; chiropractic/OMT; or orthopedic/spine surgeon evaluation); b) symptoms are not associated with another diagnosis; c) one of: (a) age ≥40 and mammogram negative for cancer within prior year; (b) <40 with symptoms or high-risk factors and mammogram negative within prior year; (c) <40 with no symptoms and no high-risk factors.

Gigantomastia of pregnancy

Covered when ALL of the following are met:

Gigantomastia of pregnancy: Member has gigantomastia of pregnancy accompanied by any of the following complications and delivery is not imminent: massive infection; significant hemorrhage; tissue necrosis with slough; ulceration of breast tissue; or intertriginous maceration or infection of the inframammary skin refractory to dermatologic measures.

Breast reconstruction and related procedures

Covered when ALL of the following are met:

Breast reconstruction: A. Reconstruction is required due to malignant neoplasm of the breast, secondary malignant neoplasm, carcinoma in situ (lobular or ductal), congenital absence of the breast (Poland’s syndrome), or prophylactic mastectomy meeting criteria; B. If required, breast implants including tissue expanders and implant materials are covered when placed in the area where natural breast tissue has been removed for a medically necessary mastectomy or to achieve symmetry after medically necessary breast surgery; C. Nipple reconstruction and/or tattooing are covered when criteria in V.A are met; D. Periprosthetic capsulotomy/capsulectomy procedures are covered for contractions or adhesions following reconstruction when caused by medically necessary chemotherapy or radiation.

Referenced clinical criteria and assessment tools

Supporting assessment elements referenced for medical necessity determinations

Adolescent assessment: Use Tanner staging (Appendix A) to evaluate breast development in adolescents when considering breast surgery; Tanner stages 1–5 are defined in Appendix A.

Reduction mammoplasty threshold: Use the Schnur Sliding Scale (Appendix B) to map body surface area (BSA) to minimum grams of tissue to be removed per breast when assessing necessity for reduction mammoplasty; values provided in Appendix B (e.g., BSA 1.35 = 199 g through ≥2.30 = 1000 g).

If resected tissue weight falls below the 22nd percentile per BSA, medical director review is required.

Procedure definitions for coverage decisions: CPT definitions provided to clarify procedural intent for peri-implant capsulectomy (19371), revision of reconstructed breast (19380), and tattooing (11920).

The policy explicitly lists procedures that are excluded as cosmetic and therefore not covered. Examples include breast implants used solely for cosmetic enlargement, removal of implants for cosmetic purposes, augmentation mammaplasty for cosmetic purposes, correction of inverted nipples, preparation of moulage for custom implants, and periprosthetic capsulotomy/capsulectomy procedures following augmentation. Additionally, breast reduction and mastopexy are not covered unless the applicable medical necessity criteria are met.

Procedures performed solely for cosmetic purposes, as enumerated in the exclusions (for example, cosmetic breast augmentation or implant removal for cosmetic reasons), are considered not covered / not medically necessary. Requests for such procedures will be denied when documentation shows the sole intent is cosmetic rather than treatment of a medical condition or reconstruction meeting clinical criteria.

For Medicaid members, state Medicaid coverage provisions take precedence when they conflict with this clinical policy. Providers should consult the applicable state Medicaid manual for specific coverage rules and follow state-level provisions where discrepancies exist.

This clinical policy is intended as a guide to medical necessity to assist with coverage determinations and benefit administration; it does not guarantee payment or direct clinical care. Providers are expected to exercise professional medical judgment and to follow applicable plan-level administrative policies and procedures when submitting documentation to support medical necessity determinations.

Coding and Measurement Rules

Referenced CPT CodesCPT

19300	Mastectomy for gynecomastia.
19301	Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy).
19302	Mastectomy, partial; with axillary lymphadenectomy.
19303	Mastectomy, simple, complete.
19305	Mastectomy, radical, including pectoral muscles, axillary lymph nodes.
19306	Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes.
19307	Mastectomy, modified radical, including axillary lymph nodes.
19316	Mastopexy.
19318	Breast reduction.
19325	Augmentation mammaplasty with implant / Breast reduction (document references 19325).

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Enumerated procedure CPT codes in this document fragmentCPT

19371	Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents.
19380	Revision of reconstructed breast (e.g., significant removal of tissue, re-advancement, and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction).
11920	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less.

Gynecomastia persistence / adolescent timing

AdultsGynecomastia persistent for more than 3 months after pathological causes are ruled out

AdolescentsGynecomastia persistent for more than 6 months after pathological causes are ruled out

ConfirmationExclusion of pathological causes required prior to timing assessment

Gynecomastia BMI requirement

Primary BMI thresholdMember BMI ≤ 30

Alternative to BMIParticipation in a clinically supervised weight loss and exercise program for >6 consecutive months

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Obtain prior authorization for referenced breast surgery CPT codes

Prior authorization is required for the breast surgery CPT codes listed in the policy; providers should obtain authorization per Health Plan administrative procedures and reference current coding guidance.

Affected codes include: 19300, 19301, 19302, 19303, 19305, 19306, 19307, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 11920.

Prior Authorization

Obtain prior authorization for enumerated CPT codes (e.g., 19371, 19380, 11920)

Prior authorization is implied and required for the specifically enumerated procedures (examples shown); obtain authorization per Health Plan administrative procedures before performing these services.

Examples of enumerated CPT codes: 19371 (peri-implant capsulectomy), 19380 (revision of reconstructed breast), 11920 (tattooing).

Definitions and Procedure Descriptions

Gigantomastia / Macromastia

DefinitionExcessive breast tissue causing significant symptoms that affect activities of daily living

Relation to reduction criteriaMinimum resection weight for reduction mammoplasty is determined by body surface area per the Schnur Sliding Scale (Appendix B)

Medical director reviewIf estimated resection weight is below the Schnur minimum (22nd percentile), case will be reviewed by medical director

Gynecomastia (surgical indication)

Core indicationPersistent glandular breast tissue in males after exclusion of pathological and reversible causes

TimingAdults: >3 months persistence; Adolescents: >6 months persistence

Background and Scope

This policy establishes medical necessity criteria and coverage guidance for a range of breast surgeries, including surgical management of gynecomastia, prophylactic mastectomy for high-risk patients, reduction mammoplasty for symptomatic macromastia or gigantomastia, and breast reconstruction following mastectomy or for severe disfigurement. It references required diagnostic confirmation (e.g., imaging and pathology for glandular tissue in gynecomastia), risk assessment or genetic testing for prophylactic indications, and objective thresholds for reduction mammoplasty such as the Schnur Sliding Scale (Appendix B) mapping body surface area to minimum grams of tissue to be removed.

Clinical Guidelines and References

This policy references clinical guidance and literature to support assessment and coverage decisions. Key bibliographic sources include the State of North Carolina Medicaid Clinical Coverage Policy No:1A-12 — Breast Surgeries, the ASPS Evidence-Based Clinical Practice Guideline Revision: Reduction Mammaplasty (2022), ASPS recommended insurance coverage criteria for reduction mammoplasty and gynecomastia, ACOG Committee Opinion on breast and labial surgery in adolescents, UpToDate reviews on gynecomastia and breast reduction, and foundational research on the Schnur Sliding Scale and body surface area calculations. These references inform thresholds, conservative therapy requirements, and adolescent assessment (Tanner staging) used by the policy.

Policy Revision History

2026-02-01policy_reviewLatest

Policy last reviewed and scheduled next review on 2026-02-01 per document metadata.

publication

Clinical policy defines medical necessity criteria for breast surgeries including mastectomy, gynecomastia, prophylactic mastectomy, reduction mammoplasty, and reconstruction.

Policy Summary

PayerPartners Health Management

PolicyBreast Surgeries

Policy CodePolicy NC.CP.MP.501

Change TypeNo material changes

Effective Date

Last ReviewFeb 1, 2026

Next Review DateFeb 1, 2026

SourceLink

On This Page

DocumentationHeight and weight must be submitted as part of required medical documentation

Reduction mammoplasty minimum resection

Minimum resection requirementEstimated breast tissue to be removed must meet minimum weight based on member's body surface area per the Schnur Sliding Scale (Appendix B)

Below-minimum reviewIf resected tissue weight falls below the 22nd percentile (minimum cutoff) per BSA, the request will be reviewed by a medical director on a case-by-case basis

BSA calculationUse DuBois and DuBois BSA calculator if only height and weight are provided

Schnur sliding scale - tissue weight per breast

Example — BSA 1.35 m2Minimum 199 grams per breast

Example — BSA 1.60 m2Minimum 310 grams per breast

Example — BSA ≥ 2.30 m2Minimum 1000 grams per breast

Range samplesAdditional BSA-to-grams mappings included (e.g., 1.45→238 g; 1.80→441 g; 2.25→978 g)

Step Therapy

Document failure of at least two conservative therapies prior to reduction mammoplasty

For reduction mammoplasty requests, include documentation showing failure of conservative therapies. The physician must document therapeutic measures and evidence that at least two conservative treatments were tried before surgery.

Acceptable conservative measures include at least two of: NSAIDs/analgesics; physical therapy/exercise when skeletal pathology present; proper supportive devices (e.g., bras, wide straps); medically supervised weight loss program; chiropractic or osteopathic manipulative treatment; orthopedic or spine surgeon evaluation of spinal pain.

Documentation Required

Include height/weight/age and unclothed pre-op photos and full supporting records

When requesting coverage for gynecomastia surgery or prophylactic mastectomy, submit the specific clinical documentation listed in the policy: height, weight, age, and unclothed pre-operative photographs (chin to waist frontal and side) plus supporting medical records and test results.

Required items include: height (inches), weight (pounds), age; unclothed pre-operative photos from chin to waist, standing frontal and side views with arms down; history and physical, diagnoses, objective signs/symptoms with duration; prior management and current medications; endocrine study results, imaging/pathology confirming glandular tissue; treatment plan including planned reconstruction where applicable.

Documentation Required

Follow plan administrative policies and provide documentation supporting medical necessity

Follow Health Plan administrative policies and supply documentation supporting medical necessity per the coverage criteria; when plan documents or state Medicaid provisions apply, those terms and limitations govern coverage determinations.

Providers must adhere to plan-level administrative procedures and coverage documents (e.g., evidence of coverage, policy, contract).
For Medicaid members, state Medicaid coverage provisions take precedence when they conflict with this clinical policy.

Denial Risk

Avoid denials for cosmetic/non–medically necessary procedures

Requests for procedures performed solely for cosmetic purposes or otherwise listed as not covered will be denied. Ensure the proposed procedure meets medical necessity criteria and is not among the policy exclusions before submitting for authorization.

Examples of procedures not covered: breast implants for cosmetic enlargement; removal of implants for cosmetic purposes; augmentation mammaplasty for cosmetic purposes; correction of inverted nipples; preparation of moulage; periprosthetic capsulotomy/capsulectomy following augmentation; breast reduction or mastopexy when medical necessity criteria are not met.

Note

Coverage decisions subject to member contract terms, exclusions and limitations

Coverage and benefit administration are subject to the terms, conditions, exclusions and limitations of the member's coverage documents; failure to meet those terms (or the policy criteria) may result in denial of coverage.

This clinical policy is a guide to medical necessity and does not guarantee payment.
Coverage determinations are governed by the member's evidence of coverage, certificate of coverage, policy or contract and applicable laws.

Documentation Required

Submit complete, criteria-specific documentation to support authorization requests

Include all requested medical records and evidence that criteria are met when submitting authorization requests; incomplete documentation (missing images, objective findings, or criteria-specific tests) may delay or result in denial.

Provide documentation demonstrating duration of symptoms, imaging/pathology confirming glandular tissue (gynecomastia), genetic or biopsy results for prophylactic mastectomy indications, and BSA/resection estimates per the Schnur Sliding Scale for reduction requests.

ConfirmationExcessive tissue must be confirmed as glandular by clinical exam and ultrasound or mammogram

Peri-implant capsulectomy (CPT 19371)

Definition (CPT 19371)Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents

ScopeComplete capsulectomy includes removal of the capsule and any intracapsular material

Use in coverage decisionsCPT 19371 is enumerated to clarify procedural intent when assessing claims for peri-implant capsule removal

Revision of reconstructed breast (CPT 19380)

Definition (CPT 19380)Revision of reconstructed breast involving significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction, or significant capsular revision combined with soft tissue excision in implant-based reconstruction

ScopeIntended to clarify major revisions rather than minor contour adjustments

Coverage contextUsed to determine medical necessity and appropriate CPT assignment for revision procedures after reconstruction

Tattooing (CPT 11920)

Definition (CPT 11920)Tattooing: intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less

Typical useNipple–areola micropigmentation following reconstruction

Size limitProcedure description specifies area of 6.0 square centimeters or less