Candidacy and insurance: Breast Reduction: Will Insurance Cover It?

Symptoms and treatmentAll macromastia conditions must be met. Symptoms in at least 2 listed areas must affect daily activity for at least 1 year. Areas include headache, neck, shoulder or upper-back pain, x-ray-confirmed painful kyphosis, painful or ulcerating strap grooves, skin breakdown and upper-extremity paresthesia. Symptoms must be primarily attributable to macromastia, with likely improvement after surgery and physician-documented pain despite at least 3 months of therapeutic measures.

Tissue and ageAge 18 or completed growth, defined as stable breast size over 1 year. Each breast must meet Aetna’s own Mosteller-BSA appendix for breast tissue, not fatty tissue. More than 1 kg per breast is an alternative with the symptom criteria still met.

Documentation and workflowHigh-quality color frontal and side photographs documenting severe hypertrophy. Negative mammogram within 2 years if age 50 or older. Measures listed include medicines, skin care, therapy/exercises/posture, supportive devices, chiropractic/osteopathic care, supervised weight loss and spine evaluation; not mandatory physical therapy alone.

Limits to applying this policyIntertrigo alone is insufficient; at least 6 months of refractory dermatologic and conservative treatment plus the other criteria are needed. Asymptomatic reduction is cosmetic; liposuction-only is unproven. The accessed pathway prints no general numeric BMI ceiling or complete authorization workflow.

Symptoms and treatmentAll conditions apply if the benefit exists. At least 1 qualifying condition unresponsive to medical management: shoulder, upper-back/neck pain or ulnar palsy after other causes are excluded, or inframammary intertrigo, dermatitis, eczema or hidradenitis. The accessed section gives no fixed treatment duration.

Tissue and ageAge at least 18 or completed breast growth. Average grams per breast above the 22nd Schnur percentile, or more than 1 kg per breast regardless of BSA.

Documentation and workflowPreoperative photographs confirm significant hypertrophy and any reported grooving or intertrigo. The benefit document supersedes policy language. No universal BMI limit or complete authorization route is printed in this section.

Limits to applying this policyAppearance-only or psychological complaints without qualifying physical findings are cosmetic. Sole-method liposuction is unproven. Nipple reconstruction and liposuction are integral to the reduction code, not separately reimbursable under this policy.

Symptoms and treatmentMost plans exclude reduction except where legally required; some exclude it even for physiological impairment. Verify the benefit before applying medical-necessity criteria.

Tissue and ageThe public policy refers to InterQual. It does not print detailed gram, BMI, age or symptom-duration thresholds to reproduce here.

Documentation and workflowMember-specific plan language governs. Documentation can support criteria without establishing benefits. Obtain the applicable InterQual requirements and product-specific authorization steps from the plan.

Limits to applying this policyA listed procedure code does not establish reimbursement. Do not import another payer’s grams or treatment duration into this document.

Symptoms and treatmentQualifying symptoms plus expected tissue removal and a reasonable prognosis of relief. Pain interfering with daily activities requires at least 3 months of adequate conservative care. Alternatives include refractory intertrigo or ulcerated shoulder grooves, or thoracic-outlet symptoms after at least 3 months of adequate conservative care.

Tissue and ageStandard BSA/mass table may be met from at least 1 breast; use the Du Bois formula. Separate large-resection route requires at least 1 kg from each breast plus a qualifying symptom condition. No general BMI ceiling or minimum age is printed in the extracted pathway.

Documentation and workflowHeight, weight, breast size and shape, symptoms and expected tissue removal. Photographs may be requested. Obtain the plan’s authorization instructions separately.

Limits to applying this policyThe restriction concerns liposuction used to perform reduction; the member summary describes liposuction alone. It is not Regence’s separate adjunct exclusion. Fit concerns or posture alone do not establish qualifying symptoms.

Symptoms and treatmentCommercial/CHIP must meet all criteria. Independent qualified practitioner documents chronic postural backache, chronic neck or upper-back pain, strap grooves or chronic/recurrent intertrigo due to hypertrophy; recommended or provided conservative treatment was unsuccessful. No competing condition is more likely to cause or significantly contribute to symptoms.

Tissue and ageEach breast or the average of both must meet or exceed one of its printed tables. BSA 1.80 lists 441 g per breast; BSA greater than 2.00 lists 600 g. Alternate table only for BMI below 30: below 60 kg (≤132 lb), 225 g; 61–79 kg (133–174 lb), 360 g; above 80 kg (≥175 lb), 575 g per breast. The printed boundary bands are preserved without interpolation.

Documentation and workflowHeight, weight and surgeon’s estimated grams from each breast. No fixed symptom/treatment duration, minimum age or photo mandate printed in this section. Preauthorization responsibility varies by product and provider; confirm it.

Limits to applying this policyMedicare refers to CMS; when no CMS determination and no InterQual criteria are available, commercial policy applies. Community Care typically follows Utah Medicaid including InterQual, with stated possible alternatives. Do not apply commercial thresholds automatically.

Symptoms and treatmentAge, tissue and at least 1 clinical route. Pain requires referring-provider records, not the operating surgeon’s, showing at least 12 months, exclusion of other causes and at least 3 months unsuccessful conservative care. Alternatives are intertrigo despite 3 months dermatologic care, x-ray-confirmed kyphosis, or ulnar paresthesia despite 3 months conservative care.

Tissue and ageEach breast meets the printed Mosteller-BSA Schnur minimum, excluding liposuction fat. With qualifying asymmetry, combined tissue must total at least twice the minimum. Age 18; the policy also prints a younger exception for age 16 or older with 12 months stable size and documented necessity before 18. This guide remains adult-only.

Documentation and workflowHeight, weight, laterality and total planned tissue, plus the records supporting the clinical route. Operative records may be reviewed for actual grams. No universal numeric BMI ceiling or photo mandate in the extracted criteria.

Limits to applying this policyAdjunct liposuction is not medically necessary; sole-method liposuction is investigational. The pending replacement was not recovered. Obtain current authorization and appeal instructions rather than applying an old contract.

Symptoms and treatmentAll criteria apply. At least 1 pain/ulnar-nerve condition or inframammary intertrigo, dermatitis, eczema or hidradenitis after at least 1 continuous 3-month appropriate medical-management trial. Other causes must be excluded or breast size documented as exacerbating the underlying condition.

Tissue and ageAge 18 or completed growth. Planned average tissue per breast must be above the printed 22nd-percentile Schnur value. At BSA 1.80 that value is 441 g.

Documentation and workflowOnly some employer groups cover the procedure. Surgery must be preauthorized and reviewed for medical necessity. Payment follows deductible and benefit percentage of maximum allowable fee.

Limits to applying this policyAppearance-only or psychological complaints without objective physical signs are excluded; sole-method liposuction is unproven. No general BMI ceiling or explicit photo requirement is printed in this pathway.

Symptoms and treatmentBreast reduction is listed among exclusions in the cosmetic/reconstructive section. Surrounding reconstructive exceptions require plan interpretation.

Tissue and ageNo general symptomatic-macromastia gram, BMI, treatment-duration or age threshold can be derived from this exclusion.

Documentation and workflowAsk the plan for a written determination for your specific product. The contract describes 1 internal appeal and 1 voluntary independent external appeal; internal filing period is 180 days with online, fax, mail or telephone routes.

Limits to applying this policyThis document does not establish an exclusion across every UUHP product or resolve the interaction with reconstructive exceptions.

Symptoms and treatmentHypertrophy plus at least 2 listed findings for at least 6 months despite reasonable nonsurgical care. Findings include attributable upper-back, neck or shoulder pain; attributable headache after other causes are addressed; correlated thoracic kyphosis; chronic weight-related breast pain; refractory inframammary maceration or infection; strap grooves; or upper-extremity paresthesia from weight-related brachial-plexus compression. Evaluation includes competing causes, support garments and refractory skin symptoms as appropriate.

Tissue and ageSurgeon documents expected tissue and rationale. No universal Schnur minimum, numeric BMI ceiling or minimum age is mandated in the opened clinical section.

Documentation and workflowClinical records must also show risk counseling and the proposed tissue amount with rationale. Obtain applicable coding and setting-specific instructions; this LCD is not a complete prior-authorization workflow.

Limits to applying this policyAppearance-driven ptosis or fit concerns are cosmetic. Only covered work is payable when cosmetic procedures are combined.

Symptoms and treatmentSymptoms refractory to nonsurgical measures plus BSA/Schnur relationship. The back-pain route lists analgesia, support and physical therapy. Shoulder grooves must be greater than 1 cm with irritation or darkening.

Tissue and ageThe evidence discussion permits bilateral reduction when at least 1 breast meets the Schnur amount and other criteria are satisfied. Use this LCD’s full logical structure and printed table.

Documentation and workflowNo complete authorization workflow is established by the excerpt. Confirm the responsible contractor and applicable records requirements.

Limits to applying this policyDo not transfer this local tissue rule to Noridian or present it as a national Medicare requirement.

Symptoms and treatmentAll requirements. Significant activity-limiting pain unrelated to other causes or nonseasonal intertrigo; at least 2 examination findings among significant grooves, obvious hypertrophy and suprasternal-to-nipple distance over 28 cm at height at least 5 ft 2 in, or over 25 cm below that height. Pain requires 6 weeks of support bra, NSAIDs if not contraindicated, exercises and heat/cold; intertrigo requires 6 weeks of hygiene, medical treatment and support bra.

Tissue and ageTissue must exceed its BSA table. BMI over 27 triggers documented weight management only for low-back pain/intertrigo with obesity contributing. The alternative documented attempt includes an initial consultation, regular visits over 3 months, diet, aerobic exercise and reasonable compliance.

Documentation and workflowPrior review required. Pictures are unnecessary for documented obvious hypertrophy. Support letters do not replace the specific medical records required.

Limits to applying this policyThis regional Blues policy is not a Utah Regence rule. No general minimum age appears in the extracted symptomatic pathway.

Symptoms and treatmentDocumentation must support medical symptoms such as pain, shoulder grooves or activity limitation.

Tissue and ageNo universal gram, BMI, age or therapy-duration cutoff printed on the public benefit page.

Documentation and workflowPhotos may be requested. Confirm referral/preauthorization with the regional contractor. Medical-necessity appeal instructions differ from factual payment appeals.

Limits to applying this policyThis is a benefit summary with special rules and limits, not individual authorization.

Symptoms and treatmentFunctional interference attributable to size with at least 2 listed findings, unsuccessful nonsurgical treatment, no evidence of breast cancer and pictures for review.

Tissue and ageAt least 450 g from each breast and BMI at or below 32 in this dated document.

Documentation and workflowObtain the current member criteria and authorization requirements. This is not verified current eligibility.

Limits to applying this policyNot a national Kaiser cutoff; historical adult pathway only.

Symptoms and treatmentSymptomatic pathway requires at least 6 months impairment plus all listed conservative conditions: weight loss, support garments, exercise and/or physical therapy, regular NSAID treatment and the implant-removal condition when applicable. These are policy descriptions, not instructions to take medicines.

Tissue and ageThe document says “at least 400gm or meets Schnur criteria for patients under BSA 1.91.” Its breast denominator and BSA qualifier remain ambiguous.

Documentation and workflowCosmetic implants must be removed at the patient’s expense before glandular reduction under the dated pathway. Obtain current criteria rather than resolving the ambiguity yourself.

Limits to applying this policyNo current national Kaiser rule follows from this regional file. Separate pregnancy-gigantomastia pathway not expanded here.

Symptoms and treatmentUtah’s public InterQual 2011 sheet cannot establish current criteria. Current NC and Humana Kentucky documents address specified reconstructive/symmetry indications, not a national symptomatic-macromastia entitlement.

Tissue and ageDo not reuse the old Utah 500 g or BMI 30 thresholds as current criteria. NC’s under-21 EPSDT provisions may affect adults 18–20 and require individualized review.

Documentation and workflowNC and Humana Kentucky require prior approval for the specified procedures. Ask your own Medicaid product for its current criteria.

Limits to applying this policyOther-state reconstructive pathways do not establish Utah benefits or a general national Humana pathway.