Reduction mammoplasty is generally performed to relieve symptoms related to the heaviness and size of the breasts. Because reduction mammoplasty may be performed for both medically necessary and cosmetic reasons, the medical need for this procedure must be established. Documentation should include significant symptoms or functional impairments that have interfered with normal daily activities for at least 6 months, and that are unrelieved by conservative treatment, such as analgesics, supportive measures, and physical therapy. The following guidelines are used when considering the medical necessity of reduction mammoplasty requests:
1. The patient is at least 18 years of age or older or for whom growth is complete (i.e., breast size stable over one year).
2. Persistent symptoms include at least two (2) of the following:
a) severe and chronic bra strap grooving
b) upper extremity paresthesia unresponsive to conservative treatments
c) back, neck, or shoulder pain unresponsive to conservative measures
d) intertrigo unresponsive to adequate treatment regimens
e) breathing difficulties attributed to excess breast mass and documented by spirometric testing
f) Chronic breast pain due to weight of the breasts
g) Thoracic kyphosis, acquired
h) Headache
i) Congenital breast deformity
3. A breast exam within the past six (6) months indicating that there are no contraindications for breast reduction surgery.
4. A mammogram within the past twelve (12) months noting no contraindications for breast reduction surgery is required for patients older than 40 years.
Approved: 2/16/01
