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HealthPartners

Coverage criteria policies

Reduction mammaplasty

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for reduction mammaplasty.

Coverage

Reduction mammaplasty is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

Reduction mammaplasty is covered according to the following criteria:

  1. A current height and weight must be measured and recorded in the medical record at the member’s primary care or specialist’s clinic.
  2. One or more of the following symptoms must be present:
    1. Documented history of chronic neck and back pain
    2. Documented history of shoulder pain
    3. Documented history of recurrent dermatitis of the skin related to large breasts. An example is intertrigo (a rash appearing between folds of skin).
    4. Documented history of grooves on shoulders from a bra.
    5. Documented history of neurologic symptoms (brachial plexus pressure)
    6. Documented respiratory symptoms
  3. Grams to be removed must comply, for at least one breast, with the Schnur Scale. See scale below.
  4. Member must meet either A. or B. below:
    1. Be at least 18 years of age, or
    2. Have completed breast growth, as evidenced by documentation of stable breast size over the preceding 12 months.
  5. Women 40 years of age or older are required to have a mammogram that was negative for cancer performed within the year prior to the date of the planned reduction mammaplasty.

Indications that are not covered

Reduction mammaplasty for cosmetic reasons without functional impairment is not covered.

Definitions

Reduction mammaplasty/ mammoplasty is a plastic surgery operation reducing the size of one or both breasts.

If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive.

CPT Codes

Description

19318

Reduction mammaplasty

ICD-10 Codes

Description

0HBT0ZZ

Excision of Right Breast, Open Approach

0HBT3ZZ

Excision of Right Breast, Percutaneous Approach

0HBU0ZZ

Excision of Left Breast, Open Approach

0HBU3ZZ

Excision of Left Breast, Percutaneous Approach

0HBV0ZZ

Excision of Bilateral Breast, Open Approach

0HBV3ZZ

Excision of Bilateral Breast, Percutaneous Approach

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Breast Reduction Criteria – Body Surface Area and Grams Needed to be Removed (from at least one breast)

Body surface area

Grams needed to be removed

Body surface area

Grams needed to be removed

Body surface area

Grams needed to be removed

1.35

199

1.66

344

1.97

596

1.36

203

1.67

351

1.98

607

1.37

207

1.68

357

1.99

617

1.38

210

1.69

364

2.00

628

1.39

214

1.70

370

2.01

640

1.40

218

1.71

377

2.02

652

1.41

222

1.72

384

2.03

663

1.42

226

1.73

390

2.04

675

1.43

230

1.74

397

2.05

687

1.44

234

1.75

404

2.06

700

1.45

238

1.76

411

2.07

712

1.46

242

1.77

419

2.08

725

1.47

247

1.78

426

2.09

737

1.48

251

1.79

434

2.10

750

1.49

256

1.80

441

2.11

764

1.50

260

1.81

449

2.12

778

1.51

265

1.82

457

2.13

791

1.52

270

1.83

466

2.14

805

1.53

274

1.84

474

2.15

819

1.54

279

1.85

482

2.16

834

1.55

284

1.86

491

2.17

849

1.56

289

1.87

500

2.18

865

1.57

294

1.88

509

2.19

880

1.58

300

1.89

518

2.20

895

1.59

305

1.90

527

2.21

912

1.60

310

1.91

537

2.22

928

1.61

316

1.92

546

2.23

945

1.62

321

1.93

556

2.24

961

1.63

327

1.94

565

2.25

978

1.64

332

1.95

575

2.26

996

1.65

338

1.96

586

2.27

*

Schnur, P. L., Hoehn, J. G., Ilstrup, D. M., Cahoy, M. J., & Chu, C-P. (1991). Reduction mammaplasty: Cosmetic or reconstructive procedure? Annals of Plastic Surgery, 27 (3), 232-7.

Methods of Calculating Body Surface Area (BSA)

Mosteller Formula

BSA = Square Root of ([Height in inches X Weight in pounds]/3131)

BSA = Square Root of ([Height in cm X Weight in kg]/3600)

Dubois & Dubois Formula

BSA = 0.007184 X Weight in kg^0.425 X Height in cm^0.725

*If grams to be removed is 1000 or greater from at least one breast, approval is granted based on medical necessity due to extreme weight of breast causing functional problems.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. American Society of Plastic Surgeons. (2011). Evidence-Based Clinical Practice Guideline: Reduction Mammaplasty. Accessed March 29, 2016. Available at URL address: http://www.guideline.gov/content.aspx?id=34042
  2. Hansen, J., & Chang, S. Overview of breast reduction. In: UpToDate, Chagpar, A. B., & Butler, C. E. (Eds), UpToDate, Waltham, MA. (Accessed on May 25, 2018.)
  3. Hayes, Inc. Hayes Medical Technology Directory Report. Reduction Mammoplasty. Lansdale, PA: Hayes, Inc.; December, 2008. Reviewed November, 2012/Archived January, 2014.
  4. Schnur, P. L., Hoehn, J. G., Ilstrup, D. M., Cahoy, M. J., & Chu, C-P.. (1991). Reduction mammaplasty: Cosmetic or reconstructive procedure? Annals of Plastic Surgery, 27 (3), 232-7.
  5. U.S. Preventive Services Task Force (USPSTF). Breast Cancer: Screening. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); Updated January 2016. Accessed March 2016. Available at URL address: http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancer-screening1

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Policy activity

  • 01/01/1994 - Date of origin
  • 07/01/2018 - Effective date
Review date
  • 05/2018
Revision date
  • 06/27/2018

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