Wiki Medicare breast reduction denial for BMI?

Community Wiki

This is a community-maintained wiki post containing the most important information from this thread. You may edit the Wiki once you have been on AAPC for 30 days and have made 5 posts. Learn More
Code: R21

Code Name: ICD-10 Code for Rash and other nonspecific skin eruption

Block: Symptoms and signs involving the skin and subcutaneous tissue (R20-R23)

Excludes 2: symptoms relating to breast (N64.4-N64.5)

Details: Rash and other nonspecific skin eruption

Includes: rash NOS

Excludes 1: specified type of rash- code to condition
vesicular eruption (R23.8)

Guidelines: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

Note: This chapter includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded.
Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters of the classification. In general, categories in this chapter include the less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point perhaps equally to two or more diseases or to two or more systems of the body. Practically all categories in the chapter could be designated 'not otherwise specified', 'unknown etiology' or 'transient'. The Alphabetical Index should be consulted to determine which symptoms and signs are to be allocated here and which to other chapters. The residual subcategories, numbered .8, are generally provided for other relevant symptoms that cannot be allocated elsewhere in the classification.
The conditions and signs or symptoms included in categories R00-R94 consist of:
(a) cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated;
(b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined;
(c) provisional diagnosis in a patient who failed to return for further investigation or care;
(d) cases referred elsewhere for investigation or treatment before the diagnosis was made;
(e) cases in which a more precise diagnosis was not available for any other reason;
(f) certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right.

Excludes 2: abnormal findings on antenatal screening of mother (O28.-)
certain conditions originating in the perinatal period (P04-P96)
signs and symptoms classified in the body system chapters
signs and symptoms of breast (N63, N64.5)

For more details on R21, ICD-10 Code for Rash and other nonspecific skin eruption , visit:


Eugene, OR
Best answers
Does anyone know if MC has BMI restrictions for a breast reduction? I've had insurance companies deny reductions before for pts who had a BMI >30, which is considered obese. They say that the symptoms of neck/back/shoulder pain would be alleviated by the pt's overall weight loss, rather than a specific surgery.

I have a pt who has a BMI of 44.8, and since MC doesn't do prior authorizations, I was hoping someone would have experience with this situation. Any ideas?
Breast surgery

Does she have any kyphosis or other back discomfort due to exceptionally large breasts? I would also wonder if there may be some neck ailments.
Last edited:
From the dr's CN: "56 yo F who has neck, shoulder, and upper back pain. She has recurrent rashes and ulcers under her breasts. She has deep grooves from her bra straps and she attributes these symptoms to her extremely large breasts. She wears a 48FF bra."

Which Medicare carrier do you submit to? You should be able to go online to your carrier and pull the local coverage determinations for 19318. I am only aware of diagnostic codes needed for Medicare to cover a reduction.

Let me know if I can help.
Here are the LCD's I came up with for Oregon for the 19316.

Group 3

Reconstructive Breast Surgery (CPT Codes 19316, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396)

174.0 Malignant neoplasm of nipple and areola of female breast
174.1 Malignant neoplasm of central portion of female breast
174.2 Malignant neoplasm of upper-inner quadrant of female breast
174.3 Malignant neoplasm of lower-inner quadrant of female breast
174.4 Malignant neoplasm of upper-outer quadrant of female breast
174.5 Malignant neoplasm of lower-outer quadrant of female breast
174.6 Malignant neoplasm of axillary tail of female breast
174.8 Malignant neoplasm of other specified sites of female breast
174.9 Malignant neoplasm of breast (female), unspecified site
175.0 Malignant neoplasm of nipple and areola of male breast
175.9 Malignant neoplasm of other and unspecified sites of male breast
198.2 Secondary malignant neoplasm of skin
198.81 Secondary malignant neoplasm of breast
217 Benign neoplasm of breast
232.5 Carcinoma in situ of skin of trunk, except scrotum
233.0 Carcinoma in situ of breast
238.3 Neoplasm of uncertain behavior of breast
239.3 Neoplasm of unspecified nature of breast
996.54 Mechanical complication due to breast prosthesis
V10.3 Personal history of malignant neoplasm of breast
V43.82 Breast replaced by other means
V52.4 Fitting and adjustment of breast prosthesis and implant
V58.42 Aftercare following surgery for neoplasm

Group 4

Reduction Mammoplasty (CPT Code 19318)
Two diagnoses are required for payment (One primary and one secondary).

Primary ICD-9-CM:

Secondary ICD-9-CMs (One of the following diagnoses*): 695.89, 719.41, 723.1, 724.1, 724.5, 782.1

*Secondary diagnoses 695.89, 719.41, 723.1, 724.1, 724.5, 782.1 must be billed with the following primary diagnosis: 611.1 (Two diagnoses are required for payment.)

611.1 Hypertrophy of breast
695.89 Other specified erythematous condition
719.41 Pain in joint, shoulder region
723.1 Cervicalgia
724.1 Pain in thoracic spine
724.5 Unspecified backache
782.1 Rash and other nonspecific skin eruption
Medicare does have a criteria but it is retired!!!! Imagine that...I haven't had Medicare deny any reduction yet. I just make sure they have the neck pain, back pain and intertrigo. Should pain also helps. They are suppose look at BMI but I don't think they do, again the criteria is retired! I think as long as your doctor finds it a medical necessity and can provide proof then they should pay. Good Luck
terridiaz......Where may I find the documentation to support that the Medicare LCD's are retired? I use an internet based software that is real time and there are several FI's that are showing LCD's in place for these procedures so I am curious about your source for comparison purposes.

I am looking for the link. If you send me your email, I can scan in the papers I have and email them to you.
I sent you my private contact information, but if you could post the link here for others to review as well, that would be awesome!

I emailed it to you this morning. The one email address wouldn't work. Let me know if you didn't receive it.