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.