Reduction Mammoplasty

Overview .............................................................. 1 Coverage Policy ................................................... 1 General Background ............................................ 2 Medicare Coverage Determinations .................... 5 Coding/Billing Information .................................... 5 References .......................................................... 6 Related Coverage Resources

Reduction mammoplasty is considered medically necessary for the treatment of macromastia (i.e., large breasts) in women at least 18 years of age, or with completed breast growth, when ALL the following criteria are met: • macromastia is causing at least ONE of the following conditions/symptoms that has been unresponsive to medical management:  shoulder, upper back/ neck pain, and/or ulnar nerve palsy for which no other etiology has been found on appropriate evaluation  intertrigo, dermatitis, eczema, or hidradenitis at the inframammary fold • preoperative photographs confirm the presence of:  significant breast hypertrophy  shoulder grooving from bra straps and/or intertrigo (if stated to be present) • average grams of tissue to be removed per breast are above the 22nd percentile on the Schnur Sliding Scale (see Appendix A) based on the individual's body surface area (BSA) or regardless of BSA, more than 1 kg of breast tissue will be removed per breast

Note: Nipple and areola reconstruction (CPT ® code 19350) is considered an integral part of a reduction mammoplasty (CPT ® code 19318) and is not separately reimbursable.
Reduction mammoplasty for either of the following indications is considered cosmetic in nature and not medically necessary: • Surgery is being performed to treat psychological symptomatology or psychosocial complaints, in the absence of significant physical, objective signs. • Surgery is being performed for the sole purpose of improving appearance.
Reduction mammoplasty is considered not medically necessary for either of the following: • As part of a staged procedure before mastectomy.
• Known BRCA1, BRCA2, p53 or PTEN mutation confirmed by genetic testing in the absence of symptomatic macromastia meeting the above medical necessity criteria.
Suction lipectomy or ultrasonically-assisted suction lipectomy (liposuction) as a sole method of treatment for symptomatic macromastia is considered unproven.

General Background
Macromastia (i.e., female breast hypertrophy) is the development of abnormally large breasts. Normal breast development begins at approximately five weeks' gestation and continues until a woman is in her early twenties, with the rate of development and degree of asymmetry often varying. Spontaneous massive growth of the breasts during puberty and adolescence is thought to be the result of excessive end-organ sensitivity to gonadal hormones. It is more commonly bilateral, often occurs over a brief period, and most commonly affects adolescent girls. Management is individualized and may range from reassurance or the use of supportive brassieres. It is recommended that surgery be delayed until late adolescence to allow complete breast development (Conner andMerritt, 2020, McGrath andPomerantz, 2012).
The presence of macromastia may cause clinical manifestations when the excessive breast weight adversely affects the supporting structures of the shoulders, neck and trunk. Increased weight on the shoulders can cause pain, fatigue in the cervical and thoracic spine, which can lead to poor posture, thoracic kyphosis and occipital headaches. Grooving or ulceration of the skin on the shoulders, pressure on the brachial plexus causing neurological symptoms in the arms and skin conditions occurring at the inframammary fold such as intertrigo, dermatitis, eczema, or hidradenitis (inflammation of the apocrine sweat glands resulting in obstruction of the ducts) may also exist. The presence of these persistent signs and painful symptoms distinguish macromastia from large, normal breasts and may prompt the need for surgical intervention ( Medical management of conditions/symptoms may include any of the following: weight loss, acupuncture, massage therapy, chiropractic treatment, adequate bra support (proper fit and wide strap support): nonsteroidal anti-inflammatory drugs (NSAIDS)/analgesia; and physical therapy, when a functional impairment exists (Hansen, et al., 2019;Collins, et al., 2002).
Reduction mammoplasty is the surgical excision of a substantial portion of the breast, including the skin and the underlying glandular tissue, until a clinically normal size is obtained. Relocation of the nipple, which may result in decreased sensation and altered lactation, may also be required during this procedure. Therefore, it has been recommended that surgery should not be performed on an individual until the breasts are fully developed.
Complications range from mild to severe and may be early or late. The most common early complication independent of reduction technique is delayed wound healing. Late complications can include, but are not limited to, seroma, scars and pseudoptosis. A BMI ≥30 kg/m 2 and smoking may increase the risk of complications. Persons who are obese or irradiated are more likely to develop infections, and smokers experienced a higher incidence of wound dehiscence than did nonsmokers (Zhang, et  The Schnur Sliding Scale is an evaluation tool that may be used to determine the appropriate amount of tissue to be removed compared to a patient's total body surface area (BSA). This can be instrumental in determining if breast reduction is being planned for a purely cosmetic reason or as a medically necessary procedure. In a survey of plastic surgeons, Schnur et al. (1991) concluded that women whose removed breast weight was less than the 5th percentile sought the procedure for cosmetic reasons and all women whose breast weight was greater than the 22nd percentile sought the procedure for medical reasons. Breast tissue regrowth following initial breast reduction in adolescence has been reported (Greydanus, et al., 2006). The growth of the female breast is generally described by five stages referred to as Tanner stages or sexually maturity rating (SMR) stages. A number of clinical correlations are noted with the SMR stages, including the timing of breast reduction at stage V (i.e., mature stage) (DeSilva, et al., 2006). In a review of elective plastic surgical procedures in adolescence, McGrath and Schooler (2004) stated "Breast development is variable but usually plateaus at 15-16 years of age. Reduction mammoplasty is postponed until breast maturity is reached. Occasionally, surgery is considered earlier when severe symptoms are encountered; there is a risk of recurrent hypertrophy, however." In general, breast maturity should have been reached prior to considering breast reduction surgery.
Reduction mammoplasty has been proposed for an individual with a known BRCA1, BRCA2, TP53 or PTEN mutation in the absence of symptomatic macromastia or as a part of staged procedure before mastectomy.
There is a paucity of evidence in the peer-reviewed scientific literature addressing these indications. The 2020 National Comprehensive Cancer Network ® (NCCN ® ) guideline on Breast Cancer Risk Reduction states that riskreducing mastectomy should generally be considered only in women with a pathogenic/likely pathogenic genetic mutation conferring a high risk for breast cancer. The NCCN guideline does not address reduction mammoplasty for an individual with a known BRCA1, BRCA2, p53 or PTEN mutation or reduction mammoplasty as part of a staged procedure before mastectomy.

Literature Review
Controlled clinical studies assessing the effectiveness of surgical removal of modest amounts of breast tissue in reducing neck, shoulder, and back pain and related disabilities in women are lacking. Despite the lack of controlled studies, reduction mammoplasty has become the standard of care for a subset of individuals with symptomatic macromastia. Evidence suggests that calculating breast reduction in correlation to each patient's body weight and height can have an effect on reducing preoperative signs and persistent physical conditions. The authors concluded that reduction mammoplasty was associated with a statistically significant improvement in physical signs and symptoms involving shoulder pain, shoulder grooving, upper/lower back pain, neck pain, intertrigo, breast pain, headache, and pain/numbness in the hands. The quality-of-life parameter of physical functioning was also statistically significant, while psychological functioning was not significant. The evidence suggests that women undergoing reduction mammoplasty for breast hypertrophy have significant postoperative improvement in preoperative signs and symptoms, quality of life, or both.

Breast Reduction by Liposuction
Suction lipectomy or ultrasonically-assisted suction lipectomy (liposuction) as a sole procedure has been introduced as an alternative method in reducing breast size. The effectiveness of liposuction, in terms of removing glandular breast tissue, rather than fatty tissue in the breast, remains to be demonstrated. Evidence supporting the effects of this approach on patient outcomes has been limited to retrospective/prospective uncontrolled studies and case series, and there are minimal long-term data comparing this technique to the standard surgical approach (Hayes, 2019;Maskovitz, et al., 2007;Sadove, et al., 2005).
A Hayes Search and Summary on reduction mammoplasty by liposuction alone concluded that there is insufficient published evidence to assess the safety and/or impact on health outcomes or patient management of liposuction as a stand-alone procedure for reduction mammoplasty in patients with macromastia (Hayes, 2019).

Professional Societies/Organizations American Society of Plastic Surgeons (ASPS):
The 2011 update (reaffirmed 2017) to the 2002 ASPS policy statement, insurance coverage criteria for third-party payors for reduction mammaplasty, recommends that justification for reduction mammaplasty should be based on the probability of relieving the clinical signs and symptoms of macromastia, not the degree of breast hypertrophy present (cup size or amount of tissue removed). Symptomatic breast hypertrophy is defined as a syndrome of persistent neck and shoulder pain, painful shoulder grooving from brassiere straps, chronic intertriginous rash of the inframammary fold, and frequent episodes of headache, backache, and neuropathies caused by heavy breasts caused by an increase in the volume and weight of breast tissue beyond normal proportions. These policy recommendations are based on the 2011 ASPS evidence based companion guideline for Reduction Mammaplasty.