Reduction Mammoplasty

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Surgery Section - Reduction Mammaplasty

Topic: Reduction Mammaplasty	Date of Origin: 01/1996
Section: Surgery	Policy No: 60
Approved Date: 10/13/2009	Effective Date: 11/01/2009
Next Review Date: 07/2011

IMPORTANT REMINDER

This Medical Policy has been developed through consideration of medical necessity, generally accepted standards of medical practice, and review of medical literature and government approval status.

Benefit determinations should be based in all cases on the applicable contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.

The purpose of medical policy is to provide a guide to coverage. Medical Policy is not intended to dictate to providers how to practice medicine. Providers are expected to exercise their medical judgment in providing the most appropriate care.

DESCRIPTION

Female breast hypertrophy, or macromastia, is the development of abnormally large breasts in the female. This condition can cause significant clinical manifestations when the excessive breast weight adversely affects the supporting structures of the shoulders, neck and trunk. Macromastia is distinguished from large, normal breasts by the presence of persistent symptoms such as shoulder, neck, or back pain, shoulder grooving, or intertrigo. This condition can be improved and the associated signs and symptoms can be alleviated by reduction mammaplasty surgery.

Reduction mammaplasty is the surgical excision of a substantial portion of the breast, including the skin and underlying glandular tissue, until a clinically normal size is obtained.

POLICY/CRITERIA

I.	In order to be considered for coverage of reduction mammaplasty, the patient must be at least 18 years.
II.	Reduction mammaplasty may be considered medically necessary when two or more of the following clinical indications and physical findings are documented to have been present for at least 12 months and these have failed to respond to appropriate conservative therapy (identified below):
	A.	Pain in the upper back, neck, shoulders, and/or arms, which must be of long-standing duration and increasing intensity as documented in the medical records by the referring physician or provider (e.g. primary care MD or chiropractor).
			This pain should be evaluated to determine that it is not associated with another diagnosis such as arthritis.
			Pain is not relieved by at least three months of conservative therapy such as an appropriate support bra with wide straps, exercises, heat/cold treatments and appropriate non-steroidal anti-inflammatory agents/muscle relaxants.
	B.	Dermatitis of the shoulder or shoulder grooving not responding to at least three months of conservative treatment including a support bra or appropriate dermatologic treatments (e.g. taking steps to eliminate friction, heat, and maceration by keeping skin cool and dry and where appropriate, topical agents).
	C.	Intertrigo between the pendulous breasts and the chest wall persisting despite at least three months of conservative dermatologic treatments (e.g. taking steps to eliminate friction, heat, and maceration by keeping skin cool and dry and where appropriate, antimycotic agents).
	D.	Kyphosis documented by x-ray.
	E.	Ulnar paresthesia not relieved by at least three months of conservative therapy such as an appropriate support bra with wide straps, range of motion exercises, physical therapy, and appropriate non-steroidal anti-inflammatory agents/muscle relaxants.
III.	The amount of breast tissue removed from each breast must be at least the minimum in grams per breast for the patient’s body surface area* according to the Schnur Sliding Scale (see below for body surface area/breast weight table).
	In cases of significant asymmetry (i.e., one breast meets criterion 3 but the other breast does not), the combined weight of the tissue removed from both breasts must total at least twice the amount required for the patient’s BSA in the chart below
IV.	The use of liposuction as the sole procedure for breast reduction is considered investigational.
V.	The use of liposuction as an additional procedure with breast reduction surgery is considered not medically necessary.

	Body Surface Area Calculator

Height:	cm in
Weight:	kg lb
Total:	m²

BSA (m²) = ( [Height(cm) x Weight(kg) ]/ 3600 )^½

e.g. BSA = SQRT( (cm*kg)/3600 )

Reference: Mosteller RD: Simplified Calculation of Body Surface Area. N Engl J Med 1987 Oct 22;317(17):1098 (letter)

BSA (in m2) = [height (cm)]0.718 X [weight (kg)]0.427 X .007449

Reference: Carey, Charles C., et al. The Washington Manual of Medical Therapeutics. (Philadelphia: Lippincott Williams & Wilkins, 1998), p.562.

*Body surface area in meters squared (m2) is calculated using the Mosteller formula:

Take the square root of:	Ht. (inches) x Wt. (lbs.)
	3,131

Body Surface Area m² and Minimum Requirement for Breast Tissue Removal

Body Surface Area m²	Grams per Breast of Minimum Breast Tissue to be Removed
1.350-1.374	199
1.375-1.399	208
1.400-1.424	218
1.425-1.449	227
1.450-1.474	238
1.475-1.499	249
1.500-1.524	260
1.525-1.549	272
1.550-1.574	284
1.575-1.599	297
1.600-1.624	310
1.625-1.649	324
1.650-1.674	338
1.675-1.699	354
1.700-1.724	370
1.725-1.749	386
1.750-1.774	404
1.775-1.799	422
1.800-1.824	441
1.825-1.849	461
1.850-1.874	482
1.875-1.899	504
1.900-1.924	527
1.925-1.949	550
1.950-1.974	575
1.975-1.999	601
2.000-2.024	628
2.025-2.049	657
2.050-2.074	687
2.075-2.099	717
2.100-2.124	750
2.125-2.149	784
2.150-2.174	819
2.175-2.199	856
2.200-2.224	895
2.225-2.249	935
2.250-2.274	978
2.275-2.299	1022
2.300-2.324	1068
2.325-2.349	1117
2.350-2.374	1167
2.375-2.399	1219
2.400-2.424	1275
2.425-2.449	1333
2.450-2.474	1393
2.475-2.499	1455
2.500-2.524	1522
2.525-2.549	1590
2.550 or greater	1662

POSITION STATEMENT

While there are some published articles concerning the use of liposuction as the sole procedure for breast reduction, none compare the outcomes of liposuction alone to standard excisional reduction mammaplasty. (4-7) Due to the paucity of scientific data concerning suction mammaplasty, it is not possible to draw conclusions concerning health outcomes, particularly with respect to the impact of this procedure on mammography results. A MEDLINE search through October 25, 2006 identified no new published data that alters this conclusion.

An updated search of the literature through March 2009 returned one additional study of liposuction alone for treatment of macromastia in twenty-four African-American women due to their high risk for complex scar formation following standard excision mammaplasty. (8) The mean aspirate was 1075 cc of fat per breast; however, the before and after liposuction pictures indicate that the participants continued to support large breasts. Outcome measures included the SF-36, EuroQol, Multidimensional Body-Self Relations Questionnaire, McGill Pain Questionnaire and Breast-Related Symptoms Questionnaire. Statistical analysis demonstrated a significant improvement in breast-related symptoms and pain. This was a relatively small, non-randomized trial and patients were not blinded to the intervention. Conclusions concerning the effect of liposuction alone on breast-related symptoms in patients with macromastia cannot be made.

REFERENCES

BlueCross BlueShield Association Medical Policy Reference Manual, Policy No. 7.01.21
Schnur PL, Hoehn JG, Ilstrup DM et al. Reduction mammaplasty: cosmetic or reconstructive procedure? Ann Plast Surg 1991 Sep;27(3):232-7
Schnur, PL, Schnur DP, Petty PM et al. Reduction mammaplasty: an outcome study. Plast Reconstr Surg 1997;100(4):875-83
Courtiss EH. Reduction mammaplasty by suction alone. Plast Reconstr Surg 1993;92(7):1276-1284
Gray LN. Liposuction breast reduction. Aesth Plast Surg 1998;22:159-162
Matarasso A. Suction mammaplasty: he use of suction lipectomy to reduce large breasts. Plast Reconstr Surg 2000;105(7):2604-7
Sadove R. New observations in liposuction-only breast reduction. Aesthetic Plast Surg 2005;29(1):28-31
Moskovitz MJ, Baxt SA, Jain AK et al. Liposuction breast reduction: A prospective trial in African American women. Plast Reconstr Surg 2007;119:718-26

Cross References

Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants, Regence Medical Policy Manual, Surgery, Policy No. 40

Codes	Number	Description
CPT	15877	Suction assisted lipectomy; trunk
	19318	Reduction mammaplasty
HCPCS	None

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