This policy version was replaced September 5, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, 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.

Definitions

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.

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

• Federal Women’s Health and Cancer Rights Act (WHCRA)
• Minnesota Statute 62A.25 Reconstructive Surgery

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):
  • Greater than or equal to the amount referenced on the Schnur Sliding Scale based on the Mosteller formula for body surface area:
    • BSA (m²)=SQR RT ([Height(in) x Weight(lb)] / 3131)
    • Online calculators are available; for example, at https://www.easycalculation.com/medical/bsa-Mostellers.php
    • https://qxmd.com/calculate/calculator_28/bmi-and-bsa-mosteller ; OR
  • Greater than 600 grams of breast tissue is planned to be removed from each breast. 
• 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:  https://www.bluecrossmn.com/sites/default/files/DAM/2020-04/X21854R02_Reduction%20Mammoplasty%20Pre-Auth%20Request%20Form_0.pdf

Appendix

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

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