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Medicare Criteria Breast Reductions

  1. Default Medicare Criteria Breast Reductions
    Medical Coding Books
    Hi I am searching the medicare website, this is for Ohio (Palmetto GBA), for Breast Reduction criteria. I have old criteria from 2005 and it was retired then, but I am looking for current information. So I can make sure what I am telling this patient, who is very upset, is correct. The info I have is....

    BMI is less than 35 AND
    Estimated gram removal 700 each breast AND
    Not related to an active endocrine abnormality AND
    Patient suffers from intertrigo that is unresponsive to conventional therapy including appropriate support garments.

    Thanks for any help.


  2. #2

    On the CMS website I found this information. I hope it helps. This is the link:

    Macromastia (breast hypertrophy) is an increase in the volume and weight of breast tissue relative to the general body habitus. Breast hypertrophy may adversely affect other body systems: musculoskeletal, respiratory, integumentary. Unilateral hypertrophy may result in symptoms following contralateral mastectomy.

    Reduction mammoplasty is performed:
    1. To reduce the size of the breasts and help ameliorate symptoms caused by the hypertrophy, and
    2. To reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery.

    Medicare medical necessity for reduction mammoplasty is limited to circumstances in which:
    1. There are signs and/or symptoms resulting from the enlarged breasts (macromastia) that have not responded adequately to non-surgical interventions, and
    2. To improve symmetry following cancer surgery on one breast.

    Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit.

    Non-surgical interventions preceding reduction mammoplasty should include as appropriate, but are not limited to, the following:
    • Determining the macromastia is not due to an active endocrine or metabolic process
    • Determining the symptoms are refractory to appropriately fitted supporting garments, or following unilateral mastectomy, persistent with an appropriately fitted prosthesis or reconstruction therapy at the site of the absent breast.
    • Determining that dermatologic signs and/or symptoms are refractory to, or recurrent following, a completed course of medical management.

    For Medicare purposes, a reasonable and necessary reduction mammoplasty could be indicated in the presence of significantly enlarged breasts and the presence of at least one of the following signs and/or symptoms:

    Back pain from macromastia and unrelieved by:
    1. Conservative analgesia;
    2. Supportive measures (garment, etc.);
    3. Physical Therapy; or
    4. Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity.

    Intertriginous maceration or infection of the inframammary skin refractory to dermatologic measures.

    Shoulder grooving with skin irritation by supporting garment (bra strap).

    The amount of breast tissue to be removed must be proportional to the body surface area (BSA) per the Schnur scale below:

    1.40–1.50 Grams of tissue to be removed per breast 218-260
    1.51–1.60 Grams of tissue to be removed per breast 261-310
    1.61–1.70 Grams of tissue to be removed per breast 311-370
    1.71–1.80 Grams of tissue to be removed per breast 371-441
    1.81–1.90 Grams of tissue to be removed per breast 442-527
    1.91–2.00 Grams of tissue to be removed per breast 528-628
    2.01–2.10 Grams of tissue to be removed per breast 629-750
    2.11–2.20 Grams of tissue to be removed per breast 751-895
    2.21–2.30 Grams of tissue to be removed per breast 896-1068
    2.31–2.40 Grams of tissue to be removed per breast 1069-1275

    Medicare coverage of reduction mammoplasty is limited to those circumstances where the medical record supports the following:

    The signs and/or symptoms have been present for at least six months

    Medical treatment and/or physical interventions have not adequately alleviated symptoms.
    Susan Ward, CPC, COC, CPC-I, CEMC, CPCD, CPRC
    AAPC ICD-10 Expert Trainer

    A small act of kindness a day can make someone's day special

  3. Default

    Thank you so much for taking the time to search I am going to check into this because we are in Ohio and it looks like this is for Wisconsin. But at least this is a start. Again thank you.


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