LCD/NCD Portal

L29267

 

REDUCTION MAMMAPLASTY

 

 

02/02/2009

 

Indications and Limitations of Coverage and/or Medical Necessity

 

• Medicare will consider reduction mammaplasty reasonable and necessary when performed in the presence of significantly enlarged breasts and the presence of at least one of the following:

o Documentation that suggests a history of back and/or shoulder pain which

 Adversely affects activities of daily living (ADLs).

 Unrelieved by conservative analgesia (e.g., such as NSAID, compresses, massage, etc.).

 Supportive measures (e.g., such as garments, back brace, etc.).

 Physical therapy.

 Correction of obesity.

o Documentation that suggests a history of significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity.

o Signs and symptoms of ulnar paresthesias (e.g., evidenced by nerve conduction studies), cervicalgia, torticollis, and acquired kyphosis.

o Signs and symptoms of intertrigonous maceration or infection of the inframammary (e.g., hyperpigmentation, bleeding, chronic moisture, and evidence of skin breakdown), skin refractory to dermatologic measures.

o Signs and symptoms of shoulder grooving with skin irritation (e.g., areas of excoriation and breakdown) by supporting garment.

• Medicare will consider reduction mammaplasty reasonable and necessary when performed to achieve symmetry following removal and/or reconstruction of a breast due to malignancy.

• Considerable attention has been given to the amount of breast tissue removed in differentiating between cosmetic and medically necessary reduction mammaplasty.

• Criteria for arbitrary minimum weight of breast tissue removed does not consistently reflect the consequences of mammary hypertrophy in individuals with a unique body habitus.

• The available literature is replete with minimum weights for resected mammary tissue.

• However, there is very little information available as to the scientific basis for these values.

• Therefore, this policy incorporates the signs and/or symptoms in indications and limitations (above) for the determination of medically reasonable and necessary reduction mammaplasty.

• Medical review and coverage determinations will be based upon this assessment approach.

 

 

CPT/HCPCS Codes

 

19318 REDUCTION MAMMAPLASTY

 

 

ICD-9 Codes that Support Medical Necessity

 

611.1 HYPERTROPHY OF BREAST

611.4 ATROPHY OF BREAST

611.71 MASTODYNIA

695.89 OTHER SPECIFIED ERYTHEMATOUS CONDITIONS

719.41 PAIN IN JOINT INVOLVING SHOULDER REGION

723.1 CERVICALGIA

723.5 TORTICOLLIS UNSPECIFIED

724.1 PAIN IN THORACIC SPINE

724.5 BACKACHE UNSPECIFIED

737.10 KYPHOSIS (ACQUIRED) (POSTURAL)

781.4 TRANSIENT PARALYSIS OF LIMB

782.1 RASH AND OTHER NONSPECIFIC SKIN ERUPTION

V10.3 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST

V51.8* OTHER AFTERCARE INVOLVING THE USE OF PLASTIC SURGERY

* According to the ICD-9-CM book, Diagnosis code V51.8 is a secondary diagnosis code and should not be billed as the primary diagnosis.

 

 

Documentation Requirements

• The medical record must be available for review upon request, and must provide the following information:

o Clinical evaluation of the signs and/or symptoms ascribed to the macromastia (gynecomastia).

o Documentation which supports the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy.

o Pathology report(s)

• Submission of pre-operative photographs is not required unless a specific request is made.

o Photographs should demonstrate the implication that supports the reduction mammaplasty procedure.

o Providers should maintain photographs in the medical record and make them available upon request.

 

 

Treatment Logic

• Macromastia (female breast hypertrophy) is the development of abnormally large breasts in the female.

• Gynecomastia is the excessive growth of the male mammary glands.

• These conditions can cause significant clinical manifestations when the excessive breast weight adversely affects the supporting structures of the shoulders, neck and trunk.

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

• Breasts are pair organs and breast hypertrophy generally affects both sides, therefore, bilateral surgery is usually performed.

• However, unilateral surgery may be performed if medically reasonable and necessary.

 

 

Sources of Information and Basis for Decision

 

American Society of Plastic and Reconstructive Surgery Reduction mammaplasty. recommended criteria for third-party payer coverage. http://www.plasticsurgery.org.

 

Antoniuk, P (2002). Breast augmentation and reduction. Obstetrics and Gynecological Clinics 29(1).

 

Chang, E; Johnson, N; Webber, B; et al (2004). Bilateral reduction mammaplasty in combination with lumpectomy for treatment of breast cancer inpatients with macromastia. American Journal of Surgery 187(5).

 

Townsend, C; Beauchamp, R; et al (2004). Sabiston Textbook of Surgery: The biological Basis of Modern Surgical Practice, 17th edition, page 2198. Elsevier.

 

02/02/2009

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/  . The LCD data hosted on this site is an exact match of what appears on the MCD.

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

 

CMS LCD REDUCTION MAMMAPLASTY