Blue Cross Blue Shield of Minnesota Medical Policy


Medical Policy:
Reduction Mammoplasty
Effective Date:
August 3, 2020
Issued Date:
June 28, 2021
Last Revision Date:
May 2020
Annual Review:
June 2021

This policy version was replaced September 5, 2022. To find the newest version, go to, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

Reduction mammoplasty, also known as breast reduction surgery, is a surgical procedure performed to reduce excess breast tissue.


Intertrigo: Inflammation that occurs in warm, moist areas of the body where two skin surfaces rub or press against each other.

Brachial plexus:  A network of nerves that conduct signals from the spine to the shoulder, arm, and hand.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

NOTE: Coverage may be subject to legislative mandates, including but not limited to the following, which apply prior to the policy statements:

I.   Reduction mammoplasty may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:

  • At least a six (6) month history of two (2) or more of the following clinical symptoms:
    • Shoulder, neck, or back pain that is not responsive to at least six (6) weeks of conservative therapy (e.g., appropriate support bra, exercises, heat/cold treatment, and appropriate non-steroidal anti-inflammatory agents [NSAIDS]/muscle relaxants);
    • Recurrent or chronic intertrigo between the pendulous breast and the chest wall;
    • Persistent shoulder grooving;
    • Neurologic symptoms associated with brachial plexus pressure (e.g., numbness or tingling of the shoulder, arm, or hand);
  • AND
  • If a bilateral procedure is planned, the weight of breast tissue to be removed from at least one breast must meet one of the following (if a unilateral procedure is planned, the breast on which surgery will be performed must meet one of the following):
  • AND
  • Preoperative breast cancer screening with imaging has been performed during the year prior to surgery for women 40 years of age or older and was found to be negative.

II.  Liposuction is considered EXPERIMENTAL/INVESTIGATIVE as a primary (i.e., stand alone) surgical procedure for breast reduction.

III. Reduction mammoplasty performed solely to remove fat and/or skin, but not the minimum specimen weight of breast tissue outlined above, is considered COSMETIC as it is performed primarily to enhance or otherwise alter physical appearance.


Documentation Submission

Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorization. In addition, the following documentation must also be included:

  • For patients with breast cancer, clinical notes documenting diagnosis of breast cancer.
  • For all other patients, clinical notes documenting:
    • Two or more clinical symptoms related to the excess breast tissue, including duration; and
    • Weight of breast tissue planned to be removed (if a range of breast tissue to be removed is submitted, the lower number will be used as the planned tissue reduction in determining medical necessity); and
    • Patient's height and weight.
  • For women 40 years of age or older: a written report documenting negative findings from a preoperative breast cancer screening with imaging performed during the year prior to surgery.

Link to Pre-Authorization Form:


Schnur Sliding Scale:  Minimum Weight of Breast Tissue Removed per Breast, as a Function of Body Surface Area


Body Surface Area

(in meters squared)

Minimum weight of tissue to be removed

per breast (grams)






























Schnur PL, Hoehn JG, Ilstrup DM, et al. Reduction Mammoplasty: Cosmetic or Reconstructive Procedure? Ann Plast Surg 1991;27(3):282-287

Denial Statements

No additional statements.


Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.

Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.

Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites. 

Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.

Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. 

These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.


CPT® codes copyright American Medical Association® 2022. All rights reserved.

CDT codes copyright American Dental Association® 2022. All rights reserved.