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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 4
Section 5.4
Reduction Mammaplasty For Macromastia
Issue Date:  October 22, 1985
Authority:  32 CFR 199.4(c)(2) and (e)(8)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  
1.0  CPT PROCEDURE CODE
19318
2.0  DESCRIPTION
2.1  Reduction mammaplasty 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. Because breasts are paired organs and macromastia usually affects both sides, bilateral surgery is performed. When there is significant one-sided hypertrophy, a unilateral breast reduction is performed. Reduction mammaplasty is usually prompted by physical necessity due to the signs and symptoms of macromastia, and is, therefore, reconstructive in nature.
2.2  Female breast hypertrophy, macromastia, is the development of abnormally large breasts. This condition can cause significant clinical manifestations when the excessive breast weight adversely affect the supporting structures of the shoulders, neck, and trunk. Macromastia is distinguished from large, normal breast by the presence of persistent, painful symptoms and physical signs.
Note:  There are wide variations in the range of normal individual height, body weight and associated breast sizes; the amount of breast tissue that must be removed to relieve symptoms therefore varies with the height and weight of each patient (e.g., a small-statured person will need proportionally less breast tissue removed to alleviate signs and symptoms of macromastia than a larger person). Guidelines for determining whether breast reduction is medically necessary include the Schnur sliding scale [Schnur, Paul L, et al, “Reduction Mammaplasty: Cosmetic or Reconstructive Procedure?” Annals of Plastic Surgery, September 1991; 27 (3): 232-7] and InterQual guidelines.
3.0  POLICY
3.1  Reduction mammaplasty is covered when signs and symptoms of macromastia are functionally significant.
Note:  Symptoms may include postural backache, upper back and neck pain, and ulnar paresthesia. Appropriate physical findings are “true” hypertrophy, and shoulder grooving and intertrigo. Signs may include poor posture and the inability to participate in normal physical activities. These may be functionally significant in some individuals.
3.2  Photo-documentation may be requested as part of a coverage determination.
4.0  EXCLUSIONS
4.1  Reduction mammaplasties solely to treat fibrocystic disease of the breast.
4.2  Reduction mammaplasty performed solely for cosmetic purposes.
4.3  Mastopexy surgery.
- END -

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