Coverage of any medical intervention discussed in a Dean Health Plan medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. Breast Surgeries MP9026

Covered Service: Yes

Prior Authorization Required: Yes

Additional For prophylactic mastectomy see MP9449 Prophylactic Information: Mastectomy. For procedures related to breast reconstruction see MP9476 Breast Reconstruction Surgery

Medicare Policy: Prior authorization is dependent on the member’s Medicare coverage. Prior authorization is not required for Medicare Cost (Dean Care Gold) and Medicare Supplement (Select) when this service is provided by participating providers. Prior authorization is required if a member has Medicare primary and Dean Health Plan secondary coverage. This policy is not applicable to our Medicare Replacement products.

BadgerCare Plus Dean Health Plan covers when BadgerCare Plus also covers the Policy: benefit.

Dean Health Plan Medical Policy: 1.0 Augmentation Mammaplasty (Mammoplasty) 1.1 Breast augmentation is considered not medically necessary and therefore is not covered except for indications outlined in MP9476. 2.0 Breast Reductions (Reduction Mammoplasty) 2.1 Breast reduction surgery for women aged 18 and older or for whom growth is complete (e.g. breast size stable over one year) requires prior authorization through the Health Services Division when ALL of the following criteria are met: 2.1.1 Significant and persistent complaints documented in the medical record for at least six (6) months involving at least two (2) of these areas: · Chronic breast pain · Pain in upper back · Headache · Pain in shoulders · Pain in neck · Upper extremity paresthesia · Pain/ discomfort/ ulceration, · Skin breakdown (severe soft shoulder grooving from bra tissue infection, tissue necrosis, straps cutting into shoulders ulceration, hemorrhage), skin

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Coverage of any medical intervention discussed in a Dean Health Plan medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. · Painful kyphosis documented by excoriation/intertrigo X-rays unresponsive to dermatology treatment

2.1.2 Pain symptoms persist as documented by the practitioner despite at least a three (3)-month trial of therapeutic measures (e.g. analgesics/non-steroidal anti-inflammatory drugs (NSAIDs) and/or muscle relaxants; dermatologic therapy physical therapy/exercises/posturing maneuvers; proper supportive devices, medically supervised weight loss program;’, orthopedic or spine surgeon evaluation of spinal pain; and chiropractic care or osteopathic manipulative treatment: AND 2.1.3 Documentation that there is a reasonable likelihood that the member’s symptoms are primarily due to macromastia; AND 2.1.4 Women 50 years of age or older are required to have a mammogram that was negative for cancer performed within the two (2) years prior to the date of the planned reduction mammoplasty; AND 2.1.5 Estimated breast tissue (Body Surface Area (BSA) based, Attachment A) to be removed must meet guidelines of the table in Attachment B. 2.1.6 Breast reduction surgery may be considered medically necessary for women meeting the symptomatic criteria, regardless of BSA, with more than one (1) kg of breast tissue to be removed per breast 2.1.7 Breast reduction surgery is considered cosmetic unless breast hypertrophy is causing significant pain, paresthesia or ulceration. 3.0 Reduction mammoplasty or mastectomy for the surgical treatment of gynecomastia requires prior authorization through the Health Services Division and is medically necessary for either pubertal (adolescent) onset gynecomastia that has persisted for at least two (2) years OR post pubertal-onset gynecomastia that has persisted for one (1) year, when ALL of the following criteria are met: 3.1 Glandular breast tissue confirming true gynecomastia is documented on physical exam and/or mammography and is not the result of obesity or puberty; AND 3.2 The condition is associated with persistent moderate to severe breast pain, despite the use of analgesics or chronic skin irritation unresponsive to treatment. The inability to participate in athletic events, sports, or social activities is not considered to be a functional impairment; AND 3.3 Gynecomastia did not regress after cessation of medications (e.g, calcium channel blockers, cimetidine, phenothiazines, spironolactone, theophylline) known to cause condition, or medications cannot be discontinued; AND

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Coverage of any medical intervention discussed in a Dean Health Plan medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. 3.4 Gynecomastia is not due to the use of anabolic steroids, illegal drugs (e.g., marijuana) or alcohol abuse; AND 3.5 The gynecomastia persists, despite correction of any underlying causes; AND 3.6 Hormonal evaluation causes, including hyperthyroidism, estrogen excess, hyperprolactinemia and hypogonadism have been excluded by appropriate laboratory testing (e.g., TSH, estradiol, prolactin, testosterone and/or luteinizing hormone , follicle stimulating hormone)) and, if present have been treated for at least 12 months before surgery has been considered. 3.7 Reduction mammoplasty or mastectomy for the surgical treatment of gynecomastia for the following indications is considered cosmetic in nature and is therefore not medically necessary: 3.7.1 When performed solely to improve appearance of the male breast or to alter contours of the chest wall 3.7.2 When performed to solely to treat psychological or psychosocial complaints 3.8 Liposuction-only reduction mammoplasty or ultrasonically-assisted liposuction, either unilateral or bilateral, is considered experimental and investigational and is therefore not medically necessary.

Committee/Source Date(s) Document Created: Policy and Clinical Improvement Committee (PCIC) August 20, 1991 Revised: — July 8, 1992 — January 17, 1994 — June 22, 1994 — March 8, 1995 — April 12, 1995 — October 23, 1995 PCIC April 1996 PCIC August 21, 1996 Utilization Management Committee December 10, 1997 Utilization Management Committee September 9, 1998 Utilization Management Committee December 9, 1998 Utilization Management Committee April 14, 1999 Utilization Management Committee June 9, 1999 Utilization Management Committee/ Genetics Counseling, Oncology, OB-Gynecology and Surgery October 13, 1999 Utilization Management Committee/ Medical Affairs Department/ Grievance Committee September 12, 2001

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Coverage of any medical intervention discussed in a Dean Health Plan medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. Committee/Source Date(s) Revised: Utilization Management Committee/ Medical Affairs and Plastic Surgery Departments December 12, 2001 Utilization Management Committee/ Medical Affairs August 14, 2002 Utilization Management Committee /Medical Affairs/ Customer Service Department July 9, 2003 Utilization Management Committee/ Medical Affairs November 12, 2003 Utilization Management Committee/Medical Affairs/Dean Plastic Surgery March 8, 2006 Utilization Management Committee/ Medical Affairs April 11, 2007 Utilization Management Committee/ Medical Affairs July 9, 2008 Utilization Management Committee/ Medical Affairs April 8, 2009 Utilization Management Committee/ Medical Affairs June 10, 2009 Medical Director Committee/Medical Affairs December 16, 2010 Medical Director Committee/Medical Affairs February 15, 2012 Medical Director Committee/Medical Affairs January 16, 2013 Medical Director Committee/Medical Affairs March 20, 2013 Medical Director Committee/Medical Affairs February 19, 2014 Medical Director Committee/Quality and Care Management Division January 20, 2016 Medical Policy Committee/Quality and Care Management Division August 17, 2016 Medical Policy Committee/Quality and Care Management Division January 18, 2017 Medical Policy Committee/Quality and Care Management Division March 21, 2018 Medical Policy Committee/Health Services Division February 20, 2019 Medical Policy Committee/Health Services Division February 19, 2020 Medical Policy Committee/Health Services Division February 17, 2021

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Coverage of any medical intervention discussed in a Dean Health Plan medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. Committee/Source Date(s) Reviewed: Health Services February 17, 1999 Managed Care Division/ Medical Affairs Department March 20, 2000 Utilization Management Committee April 12, 2000 Utilization Management Committee/ Dean General Surgery Department October 11, 2000 Managed Care Division / Medical Affairs Department April 11, 2001 Utilization Management Committee/CMO/Director UM March 13, 2002 Utilization Management Committee/ Medical Affairs October 9, 2002 UM Committee (UMC)/Director UM/UMC Chair March 12, 2003 UM Committee (UMC)/Director UM/UMC Chair March 10, 2004 Utilization Management Committee/Medical Affairs/ Medicare Part B, 8/2004 November 10, 2004 UM Committee (UMC)/Director UM/UMC Chair March 9, 2005 Reformatted February 2006 UM Committee (UMC)/Director UM/UMC Chair March 14, 2007 UM Committee (UMC)/Director UM/UMC Chair March 12, 2008 Medical Director Committee/Medical Affairs December 16, 2010 Medical Director Committee/Medical Affairs November 30, 2011 Medical Director Committee/Medical Affairs February 15, 2012 Medical Director Committee/Medical Affairs August 15, 2012 Medical Director Committee/Medical Affairs January 16, 2013 Medical Director Committee/Medical Affairs March 20, 2013 Medical Director Committee/Medical Affairs January 15, 2014 Medical Director Committee/Medical Affairs February 19, 2014 Medical Director Committee/Medical Affairs January 21, 2015 Medical Director Committee/Quality and Care Management Division January 20, 2016 Medical Policy Committee/Quality and Care Management Division August 17, 2016 Medical Policy Committee/Quality and Care Management Division January 18, 2017 Medical Policy Committee/Quality and Care Management Division March 21, 2018 Medical Policy Committee/Health Services Division February 20, 2019 Medical Policy Committee/Health Services Division February 19, 2020 Medical Policy Committee/Health Services Division February 17, 2021

Published/Effective: 03/01/2021

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Coverage of any medical intervention discussed in a Dean Health Plan medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. Breast Surgeries MP9026 Attachment A Body Surface Area (BSA) Cautionary note: With increased age, height may decrease due to kyphotic changes which may make the surface area in the nomogram inaccurate. Since obtaining height in elderly is rather 0.805 difficult and/or inaccurate, some clinicians use: BSA = 0.06 (BWkg )

BSA table is taken from the Geriatric Dosage Handbook, 3rd Edition 1997-1998.

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Coverage of any medical intervention discussed in a Dean Health Plan medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policy and to applicable state and/or federal laws. Breast Surgeries MP9026 Attachment B Table Body Surface Area (BSA)* Amount of breast tissue to be removed 1.3 to 1.6 At least 300 grams per side 1.61 to 1.9 At least 500 grams per side 1.91 to 2.2 At least 700 grams per side >2.21 At least 900 grams per side *See Attachment A

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