CG-SURG-71 Reduction Mammaplasty

This policy addresses reduction mammaplasty (breast reduction) and distinguishes it from liposuction-only breast reduction. It is considered medically necessary when symptomatic macromastia causes documented functional impairment and persists despite at least 3 months of appropriate conservative therapy, such as: cervical/thoracic pain interfering with daily activities attributable to breast weight; refractory submammary intertrigo or shoulder grooving with ulceration; or thoracic outlet syndrome (including ulnar paresthesias) related to breast size. It is not covered when these criteria are not met, including for breast cancer risk reduction, liposuction-only reduction, or cosmetic concerns such as poor posture, breast asymmetry, pendulousness, clothing fit issues, or nipple-areola distortion.

"Reduction mammaplasty is consideredmedically necessarywhen either of the following criteria (I or II) are met:"