Reduction Mammaplasty Recommended Criteria for Third-Party Payer Coverage from the ASPS
Background: The American Society of Plastic Surgeons (ASPS) is the largest organization of plastic surgeons in the world. Requirements for membership include certification by the American Board of Plastic Surgery. As the umbrella organization for the specialty, ASPS represents 97 percent of 5,000 of the board-certified surgeons practicing in the United States and Canada. It serves as the primary educational resource for plastic surgeons and as their voice on socioeconomic issues. ASPS is recognized by the American Medical Association (AMA), the American College of Surgeons (ACS) and other organizations of specialty societies.
Definitions: Macromastia (Female Breast Hypertrophy) Female breast hypertrophy, 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, painful symptoms and physical signs. This condition can be improved and the associated clinical signs and symptoms can be alleviated by reduction mammaplasty surgery. Surgery for macromastia is considered reconstructive in nature and should be compensable by insurance plans that cover reconstructive surgery. When breast reduction is performed solely to improve a patient's appearance in the absence of any signs and/or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature. It is the opinion of the ASPS that a cosmetic reduction mammaplasty is not a compensable procedure unless specifically indicated in the patient's insurance policy.
Cosmetic and Reconstructive Surgery: For reference, the following definition of cosmetic and reconstructive surgery was adopted by the American Medical Association, June 1989: Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumor or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.
Procedures: 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 generally affects both sides, bilateral surgery is usually performed. General anesthesia is most often required and post- operative hospitalization is expected. A second plastic surgeon may serve as an assistant to shorten the operative time, diminish the risk of operative complications, and reduce overall costs. Post-operatively, patients are clinically stable and usually able to return to full activity within four to six weeks. The need for secondary surgery such as scar revision is low. CPT: 19318, 19318-50 Occasionally, when there is significant, one-sided hypertrophy, a unilateral breast reduction is performed. Such a procedure may also be needed to match the contralateral side when the opposite breast has been reconstructed after mastectomy. CPT: 19318
Indications: Reduction mammaplasty is usually prompted by physical necessity due to the signs and symptoms of macromastia, and is, therefore, reconstructive in nature. However, it may be performed for other indications as well.
Medically Indicated Signs and Symptoms: Medically indicated symptoms include postural backache (ICD-9: 724-5,781.9), upper back and neck pain (ICD-9: 724.1,723.1), and ulnar paresthesia (782.0). Appropriate physical findings are "true" hypertrophy (611.1), and shoulder grooving and intertrigo (695.89).
Mixed Indications: Mixed symptoms include breast pain, inability to lose weight in the breast, and embarrassment. Signs include breast tenderness/pain in breast (611.71), mild breast asymmetry (611.8), poor posture (781.9) and the inability to participate in normal physical activities. These may be functionally significant in some individuals.
Cosmetic Signs and Symptoms: Cosmetic signs and symptoms include ptosis, poorly fitting clothing, unacceptable appearance and nipple-areolar distortion (V50.1). These are indications for patients undergoing a purely cosmetic reduction mammaplasty. Recommendations: Specific weight guidelines for breast-tissue resection or reduction in bra-cup size are not valid criteria for insurance coverage since they are poorly correlated with relief of the symptoms of macromastia. There are wide variations in the range of normal female 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 (for example, a small-statured woman will need proportionally less breast tissue removed to alleviate signs and symptoms of macromastia than a larger woman). Schnur (see references) has provided a logarithmic chart comparison of body surface area and excess breast tissue removed at surgery that allows separation of symptomatic women from those seeking a change in appearance.
Documentation: Justification for reduction mammaplasty should be based on the probability of relieving the clinical signs and symptoms of macromastia. When this surgery is performed, the clinical signs and symptoms should be documented by the surgeon in the patient's history and physical and reiterated in the operative note. These documents, as well as the pathology report, should be submitted to the insurance carrier as support documentation. Preoperative mammography is strongly recommended to rule out parenchymal breast disease (such as cancer) prior to any breast procedure. Pre-authorization by third-party payer is strongly recommended.
Photographs: Photographs are usually taken to document preoperative condition and aid the surgeon in planning surgery. In some cases, they may record physical signs; however, they do not substantiate symptoms and should only be used by third-party payers in conjunction with the patient's history and physical examination. It is the recommendation of ASPS that photographs of the breast be taken when the patient is in an upright position. In circumstances when photographs may be useful to a third-party payer, a plastic surgeon should provide them. The patient, however, must sign a specific photographic release form and strict confidentially must be honored. It is the opinion of ASPS that a board-certified plastic surgeon should evaluate all submitted photographs.
Position Statement: It is the position of the American Society of Plastic Surgeons that reduction mammaplasty is reconstructive when performed to relieve specific clinical signs and symptoms related to female breast hypertrophy. As such, reduction mammaplasty is medically necessary and should be compensable by third-party payers. The amount of tissue removed should not be the exclusive criterion for determining the intent of the operation.
- Letterman, G., and Schurter, M., "The Effects of Mammary Hypertrophy on the Skeletal System." Annals Plastic Surgery, 5:425, 1980.
- Bostwick, J., "Breast Reduction in Aesthetic and Reconstructive Surgery". St. Louis: C.V. Mosby, 1983
- Spicer, T.E., "Reduction Mammaplasty and Mastopexy": Selected Readings in Plastic Surgery, Dallas: Baylor Univ. Med. Ctr. 5:29.
- Strombeck, J.O., "Reduction Mammaplasty." Surgical Clinics of North America, 51:2, 1971
- Schnur, Paul :., et. al., "Reduction Mammaplasty: Cosmetic or Reconstructive Procedure?" Annals of Plastic Surgery, Vol. 27:232-237, 1991.
- Gonzalez, F., et. Al., "Reduction Mammaplasty Improves Symptoms of Macromastia," Plastic and Reconstructive Surgery 91:1270-1276, 1993
Prepared by The Socioeconomic Committee Approved by the American Society of Plastic and Reconstructive Surgeons Board of Directors, June 1994
Read a letter written by a patient to her insurance company requesting breast reduction after being denied coverage. The operation was approved after the repeated efforts by the woman and her doctors.