Coverage of any medical intervention discussed in a WellFirst Health 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

WellFirst Health 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 parathesias · Pain/discomfort/ulceration · Skin breakdown (severe soft shoulder grooving from bra tissue infection, tissue necrosis, straps cutting into shoulders ulceration, hemorrhage), skin · 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 6-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.

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Coverage of any medical intervention discussed in a WellFirst Health 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. 2.1.3 Documentation that there is a reasonable likelihood that the member’s symptoms are primarily due to macromastia.

2.1.4 A negative mammogram within 12 months of planned surgery if female and age is ≥ 40

2.1.5 Estimated breast tissue (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 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, parasthesias 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. 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. 3.3 The use of potential gynecomastia-inducing drugs (e.g., bicalutamide, cimetidine, human growth hormone, spironolactone, ketoconazole, nifidepine) and substances has been identified and discontinued for at least one (1) year, when medically appropriate. 3.4 Gynecomastia is not due to the use of anabolic steroids, illegal drugs (e.g., marijuana) or alcohol abuse. 3.5 The gynecomastia persists, despite correction of any underlying causes. 3.6 Hormonal causes, including hyperthyroidism, estrogen excess, hyperprolactinemia and hypogonadism have been excluded by appropriate laboratory testing (e.g., TSH, estradiol, prolactin, testosterone and/or LH) and, if present have been treated for at least 12 months before surgery has been considered.

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Coverage of any medical intervention discussed in a WellFirst Health 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. 3.7 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: Medical Policy Committee/Health Services Division February 20, 2019 Revised: Medical Policy Committee/Health Services Division February 19, 2020 Reviewed: Medical Policy Committee/Health Services Division February 19, 2020

Effective: 03/01/2020

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Coverage of any medical intervention discussed in a WellFirst Health 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 WellFirst Health 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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