CurrentWPS Health InsurancePolicy PUM 250-0029-1712

Reduction Mammoplasty (Breast Reduction Surgery) for Symptomatic Macromastia

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This guideline governs when breast reduction surgery is medically necessary for adults with symptomatic macromastia and identifies documentation, benefit limitations, cosmetic services, and experimental procedures. Coverage remains subject to the member's benefit plan, applicable law, and plan-specific exclusions.

Policy Summary

PayerWPS Health Insurance

PolicyReduction Mammoplasty (Breast Reduction Surgery) for Symptomatic Macromastia

Policy CodePolicy N/A

Change TypeAdministrative title revisionno material coverage change

Effective DateOct 1, 2026

Last ReviewSep 10, 2026

Next Review DateN/A

Key ActionSubmit surgeon documentation and photographs supporting the expected tissue removal, Schnur Scale criteria, breast size, nipple position, and relevant skin findings.

SourceLink

POLICY UPDATE CHANGES

The guideline title was changed to Reduction Mammoplasty (Breast Reduction Surgery) for Symptomatic Macromastia.

18 yearsMinimum age

3 of 7Required symptoms

>21 cmNipple position threshold

2 years

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CurrentWPS Health InsurancePolicy PUM 250-0029-1712

Reduction Mammoplasty (Breast Reduction Surgery) for Symptomatic Macromastia

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Sign up for WPS Health Insurance Policy PUM 250-0029-1712 alerts

Get alerted when Policy PUM 250-0029-1712 changes without checking for updates manually.

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Policy Summary

PayerWPS Health Insurance

PolicyReduction Mammoplasty (Breast Reduction Surgery) for Symptomatic Macromastia

Policy CodePolicy N/A

Change TypeAdministrative title revisionno material coverage change

Effective DateOct 1, 2026

Last ReviewSep 10, 2026

Next Review DateN/A

Key ActionSubmit surgeon documentation and photographs supporting the expected tissue removal, Schnur Scale criteria, breast size, nipple position, and relevant skin findings.

SourceLink

POLICY UPDATE CHANGES

The guideline title was changed to Reduction Mammoplasty (Breast Reduction Surgery) for Symptomatic Macromastia.

18 yearsMinimum age

3 of 7Required symptoms

>21 cmNipple position threshold

2 years

4 weeksPain-treatment trial

3 monthsBreast-support trial

Medical Necessity and Coverage Limitations

Medical necessity for symptomatic macromastia

Reduction mammoplasty is medically necessary for symptomatic macromastia only when ALL of criteria A through F are met.

Required coverage criteria

A. Breast size and configuration: Submitted photographs show excessively large, pendulous natural breasts without implants that are out of proportion to the individual's normal or usual body build, OR photographic measurement shows that the nipple positions are more than 21 cm below the suprasternal notch.>21 cm below the suprasternal notch when using the measurement pathway
Either the photographic body-build comparison or the nipple-position measurement pathway may satisfy criterion A.
B. Macromastia-related symptoms
- B1: Photographs show severe grooves or skin wounds on the shoulders caused by bra straps.
- B2: Photographs show chronic intertriginous dermatitis despite appropriate dermatologic treatment.
  Document each dermatologic treatment tried or applied, how long it was used, and whether it successfully healed or failed to heal the affected areas.
- B3: Pain symptoms such as headaches, neck pain, shoulder pain, or upper-back pain are present.
- B4: Breast pain is caused by the heaviness or weight of the breasts.
- B5: Symptoms of ulnar nerve compression or upper-extremity paresthesia are caused by shoulder pressure from bra straps.
  Symptoms may include loss of sensation, loss of finger coordination, tingling or burning, weakness, or reduced grip strength.
- B6: Difficulty or inability to perform physical activities is caused by excessively large breasts.
- B7: Arm symptoms are consistent with brachial plexus compression syndrome.
  Symptoms may include electric-shock or burning sensations down the arm, numbness, or arm weakness.
C. Mammogram when age 40 or older: If the individual is 40 years old or older, a mammogram performed within the past two years must be documented as negative for breast cancer.Mammogram within 2 years; negative for breast cancer
This criterion applies only to individuals age 40 or older.
D. Conservative treatment failure
- D1. Pain treatment: A four-week trial of physical therapy, chiropractic treatment, or anti-inflammatory medication must be completed without relief of pain symptoms, unless anti-inflammatory medication is contraindicated.4 weeks
  At least one listed pain-treatment approach is required; anti-inflammatory medication is not required when contraindicated.
- D2. Breast support: A three-month trial of a properly fitted bra and improved undergarment breast support must be completed without relief of symptoms.3 months
E. Expected tissue removal: The surgeon must document the amount of breast tissue expected to be removed and indicate that the amount meets Schnur Scale criteria based on the individual's body surface area.Expected tissue removal meets Schnur Scale criteria for the individual's BSA
F. Minimum age: The individual must be at least 18 years old.>=18 years

Benefit-plan exclusion: Many benefit plans exclude reduction mammoplasty and provide no coverage or benefit unless the procedure is related to mastectomy for breast cancer. Verify the member’s applicable benefit plan before services are provided.

Reduction mammoplasty requested to treat breast asymmetry related to a congenital condition or puberty is considered cosmetic when it does not improve physiologic function. Cosmetic services are not covered under the stated limitation.

Mastopexy (breast lift) is considered cosmetic and not medically necessary. An exception applies when mastopexy is performed as part of breast reconstruction after mastectomy for breast cancer.

Liposuction-only reduction mammoplasty is considered experimental, investigational, and unproven to affect health outcomes because of a lack of high-quality evidence.

Reduction mammoplasty requested or used for a condition or diagnosis not listed in the indications of coverage is considered not medically necessary.

When the required symptomatic macromastia criteria are not met, reduction mammoplasty is not medically necessary even if the diagnosis is listed in the indications of coverage. The procedure may also be considered cosmetic under the applicable limitation.

Repeat breast reduction for macromastia is considered not medically necessary.

Reduction mammoplasty requested to treat psychological or psychosocial symptoms, or requested solely to improve appearance without meeting the symptomatic macromastia criteria, is considered not medically necessary.

Documentation and Submission Requirements

Documentation Required

Standard Written Order Required

Submit a Standard Written Order prescribed by a qualified healthcare provider that identifies the member’s diagnosis and the requested reduction mammoplasty service.

Documentation Required

Medical Records Required

Provide medical records supporting the diagnosis, medical necessity, and, when applicable, continued need or use. Include relevant office notes from the consulting or referring physician and other records documenting the member’s symptoms and treatment history.

Documentation Required

Surgeon Documentation and Photographs

The surgeon must document the clinical findings and planned procedure, including the expected amount of breast tissue removal and the measurements needed to evaluate eligibility under the Schnur Scale. Submit photographs and supporting body measurements with the records.

Policy Context

Symptomatic macromastia involves abnormally large, pendulous breasts that cause physical symptoms or functional limitations. This guideline addresses when breast reduction surgery may be medically necessary based on breast configuration, qualifying symptoms, conservative-treatment failure, age, mammography when applicable, and expected tissue removal. Coverage remains subject to the member’s benefit plan, including applicable exclusions and limitations; many plans exclude reduction mammoplasty unless it is related to mastectomy for breast cancer.

Key Terms

Symptomatic macromastia

DefinitionAbnormally large breasts that are excessively large and pendulous relative to the individual's normal or usual body build.

Coverage descriptionNatural breasts are excessively large and pendulous, without implants, and out of proportion to the individual's normal or usual body build.

Alternative measurementA photographic measurement may show that the nipple positions are more than 21 cm below the suprasternal notch.

Chronic intertriginous dermatitis

DefinitionSkin inflammation caused by skin-on-skin contact that has not improved with prescription skin treatments.

Treatment statusThe dermatitis persists despite appropriate dermatologic treatment.

Policy Summary

PayerWPS Health Insurance

PolicyReduction Mammoplasty (Breast Reduction Surgery) for Symptomatic Macromastia

Policy CodePolicy N/A

Change TypeAdministrative title revisionno material coverage change

Effective DateOct 1, 2026

Last ReviewSep 10, 2026

Next Review DateN/A

Key ActionSubmit surgeon documentation and photographs supporting the expected tissue removal, Schnur Scale criteria, breast size, nipple position, and relevant skin findings.

SourceLink

On This Page

Document excessively large, pendulous natural breasts without implants, or photographic measurement showing nipple positions more than 21 cm below the suprasternal notch.
Include the member’s height and weight or body surface area (BSA), the expected tissue removal amount, and confirmation that the amount meets Schnur Scale criteria.
Submit photographs showing the breast findings and qualifying symptoms when applicable, including shoulder grooves or wounds and chronic intertriginous dermatitis.

Documentation Required

Document Dermatitis Treatment History

For chronic intertriginous dermatitis attributed to macromastia, document the treatment history and response for each dermatologic treatment attempted.

Identify each skin treatment tried or applied.
State how long each treatment was used.
Document whether each treatment successfully healed the affected areas or failed to do so.

Billing Rule

Coding Compliance

Use the correct coding for the item or service and ensure that the claim and supporting documentation comply with all applicable coding guidelines.

Note

Verify Plan Benefit

Verify the member’s specific benefit plan before submission. Many plans do not cover reduction mammoplasty unless it is related to mastectomy for breast cancer, and coverage is subject to the applicable plan terms, exclusions, limitations, network status, and law.

Review the member’s benefit plan document for coverage details.
Contact customer service using the information on the member’s member ID card when plan or benefit status is unclear.

Denial Risk

Non-Covered Indications

Requests for diagnoses or conditions not listed in the indications of coverage, or requests that do not satisfy the qualifying criteria, are not medically necessary and may be denied. Cosmetic services are not covered under the guideline.

Congenital or pubertal breast asymmetry without improvement of physiologic function is considered cosmetic.
Psychological or psychosocial symptoms, or improving appearance alone, do not qualify without meeting the symptomatic macromastia criteria.

Denial Risk

Repeat Reduction or Mastopexy

Repeat breast reduction for macromastia is considered not medically necessary. Mastopexy is cosmetic and not covered unless it is performed as part of breast reconstruction after mastectomy for breast cancer.

Denial Risk

Liposuction-Only Procedure

Liposuction-only reduction mammoplasty is considered experimental, investigational, and unproven to affect health outcomes because of insufficient high-quality evidence; it is therefore not covered as medically necessary under the guideline.

Denial Risk

Criteria Not Met

Coverage is at risk when any required symptomatic macromastia criterion is not satisfied. The procedure may be considered cosmetic or not medically necessary and denied when the required indications and documentation are incomplete.

All applicable criteria for breast size or measurements, qualifying symptoms, age, mammography when required, conservative treatment trials, Schnur Scale tissue-removal requirements, and minimum age must be documented.
The member must be at least 18 years old.
Members age 40 or older must have a negative mammogram performed within the past two years.
Document at least three qualifying macromastia-related symptoms that have not improved with conservative treatment, plus the required pain-treatment and properly fitted bra or undergarment-support trials.

Required documentationThe medical record must identify each dermatologic treatment tried or applied, how long it was used, and whether it successfully healed or failed to heal the affected areas.

Suprasternal notch

DefinitionThe visible dip between the neck and the two collarbones.

Measurement useIt is the anatomical reference point used to measure nipple position in the photographic assessment.

Coverage thresholdA photographic measurement showing nipple positions more than 21 cm below the suprasternal notch may satisfy the breast-size and configuration criterion.

Body surface area (BSA)

DefinitionBody surface area (BSA) is used with the expected amount of breast tissue removal to assess whether the Schnur Scale criteria are met.

Documentation requirementThe surgeon must document the amount of breast tissue expected to be removed.

Coverage determinationThe surgeon must indicate that the expected amount of tissue removal meets Schnur Scale criteria based on the individual's BSA.