Download Reduction mammoplasty

Reduction mammoplasty
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 mammoplasty.
Coverage
Reduction mammoplasty is generally covered subject to the indications listed below and per your plan documents.
Indications that are covered
Reduction mammoplasty 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:
A.
Documented history of chronic neck and back pain
B.
Documented history of shoulder pain
C.
Documented history of recurrent dermatitis of the skin related to large breasts. An example
is grooves on shoulders from a bra.
D.
Documented history of neurologic symptoms (brachial plexus pressure)
E.
Documented respiratory symptoms
3.
Grams to be removed must comply, for at least one breast, with the Schnur Scale. See scale
below.
4.
Reduction mammoplasty in patients less than 18 years old will be determined on a case by case
basis, per criteria listed above.
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 mammoplasty.
Indications that are not covered
Reduction mammoplasty for cosmetic reasons without functional impairment is not covered.
Definitions
Reduction mammoplasty is a plastic surgery operation reducing the size of one or both breasts.
Codes
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
19318
Description
Reduction mammoplasty
ICD-10 Codes
0HBT0ZZ
0HBT3ZZ
0HBU0ZZ
0HBU3ZZ
0HBV0ZZ
0HBV3ZZ
Description
Excision of Right Breast, Open Approach
Excision of Right Breast, Percutaneous Approach
Excision of Left Breast, Open Approach
Excision of Left Breast, Percutaneous Approach
Excision of Bilateral Breast, Open Approach
Excision of Bilateral Breast, Percutaneous Approach
CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical
Association.
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Breast Reduction Criteria – Body Surface Area and Grams Needed to be Removed (from at least one breast)
Body surface
Grams needed
Body surface
Grams needed
Body surface
Grams needed
area
to be removed
area
to be removed
area
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, Paul L, et al., “Reduction Mammaplasty: Cosmetic or Reconstructive Procedure:” Annals of Plastic Surgery. Sept 1991; 27
(3): 232-7.
BSA = Square Root of (Height in inches X Weight in pounds)/3131
*If grams to be removed is 1000 or greater from at least one breast, approval 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.
Number R001-06; Medical Directors Committee and Benefits Committee Approval 01/01/94, 5/2/2016; Revised
06/01/00, 12/6/12, 5/2/16; Annual Review 06/01/06, 8/1/07, 8/1/08, 9/9/09, 5/18/10, 5/2011, 5/2012, 4/2013, 5/2014,
5/2015, 5/2016, 5/2017
References
1.
2.
3.
Schnur, Paul L, et al., “Reduction Mammaplasty: Cosmetic or Reconstructive Procedure:” Annals of Plastic Surgery. Sept
1991; 27 (3): 232-7.
American Society of Plastic Surgeons. Reduction Mammaplasty. Evidence-Based Practice Guidelines. May 2011.
Accessed March 29, 2016. Available at URL address: http://www.guideline.gov/content.aspx?id=34042
Hayes Directory, “Reduction Mammoplasty”, December 18, 2008. Archived January 2014.
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4.
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
UpToDate, “Overview of Breast Reduction”,. June 21, 2016
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