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Medicare breast reduction denial for BMI?

  1. #1
    Eugene, OR
    Question Medicare breast reduction denial for BMI?
    Medical Coding Books
    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?

  2. #2
    Seacoast- Dover New Hampshire
    Default 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 by kbarron; 07-10-2008 at 11:46 AM. Reason: additional comment
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  3. #3
    Eugene, OR
    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."

  4. #4

    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.
    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

  5. #5
    Eugene, OR
    Lordy, there's more than one Medicare? We're in Oregon... does that mean anything?

  6. #6

    Hopefully this link will take you right where you need to go. There is only one CMS but carriers like Trailblazers, Noridian... there are a few of.

    Enjoy the reading...
    Last edited by Susan; 07-14-2008 at 02:24 PM.
    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

  7. #7
    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

  8. Talking
    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

  9. #9
    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.


  10. Default
    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.

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