Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Breast reduction may not be covered by all benefit plans. If it is a covered service, it requires pre-authorization.  Your individual Certificate of Coverage, Evidence of Coverage, or Summary Plan Description will govern the coverage for this procedure. 

2)    Breast reduction of a single breast is covered when done in conjunction with covered reconstruction of a breast removed, to achieve symmetry. See BI366.

3)    Definition: Breast reduction is the surgical excision of a substantial portion of the breast, including the skin and underlying glandular tissue.  It is intended to reduce the size of the breast, change the shape, and/or lift the breast tissue.  Breast reduction includes the repositioning of the nipple.  General anesthesia is required.

1)    Breast reduction requires preauthorization when it is not specifically excluded.

2)    QualChoice will cover Breast reduction when the following requirements are met:

a)    Breast reduction is not excluded in the plan documents (SEE LIMITATIONS OF COVERAGE CONTAINED IN THE COC, EOC OR SPD), AND

There is documentation of macromastia, AND the procedure meets medical necessity criteria based on the following items:

(1)  Photos must be submitted to document breast size; AND

(2)  An evaluation that includes an assessment of any functional physical limitations related to back pain and/or interference with the patient’s ADLs has been completed; AND

(3)   An estimate of the amount of breast tissue to be reduced from each breast, and the height and weight of the patient is included with the request, and must meet the criteria of the attached nomogram (adapted from Schnur). OR

(5)The reduction mastectomy is being performed to provide symmetry following a mastectomy on the opposite breast. See BI366.

3)    A pre-operative diagnostic mammogram is recommended prior to the procedure.

Codes Used In This BI:

19318             Breast reduction (Code revised eff 01-01-2021)

Breast reduction- Nomogram

Asymmetry of the breasts, intertrigo, and ptosis of the breasts, poorly fitting clothing, and unacceptable appearance are not considered valid reasons for coverage of Breast reduction. Breast reduction of a single breast is covered when done in conjunction with reconstruction of a breast removed for cancer, to achieve symmetry.

Anticipated removal of less than the amount of breast tissue noted on the attached Schnur nomogram is considered cosmetic.  Cosmetic surgery is typically not a covered service; see your plan documents.

Schnur PL et al.  Breast reduction: cosmetic or reconstructive procedure? Ann Plast Surg. 1991 Sep; 27(3):232-7.

This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail.  State and federal mandates will be followed as they apply.