Breast Reduction Surgery and Gynecomastia Surgery

Reduction mammoplasty is covered as medically necessary (not cosmetic) for women ≥18 or with completed breast growth when macromastia or pregnancy-related gigantomastia criteria are met; cosmetic reductions are excluded. Key requirements: symptoms in ≥2 specified anatomic areas affecting daily activities for ≥1 year, failure of ≥3 months of specified conservative therapies, high-quality photos documenting severe hypertrophy, surgeon-estimated minimum grams to be removed per breast based on Mosteller BSA (exception if >1,000 g removed per breast), and a negative mammogram within 2 years for women ≥50; gigantomastia of pregnancy is covered only for severe complications (infection, hemorrhage, necrosis, ulceration, or major asymmetry) if delivery is not imminent.

"C. Breast asymmetry: referral to CPB 0185 (Breast Reconstructive Surgery) for medical necessity criteria for surgery to correct breast asymmetry."