Clinical Medical Policy Department Clinical Affairs Division

Reduction [For the list of services and procedures that need preauthorization, please refer to www.mcs.com.pr. Go to “Comunicados a Proveedores”, and click “Cartas Circulares”.]

[Coverage for MCS Life Commercial Only]

[For MCS Advantage Classicare LOB Coverage, please refer to Local Coverage Determination for Reduction Mammaplasty (L33939)]

Medical Policy: MP-SU-03-09 Original Effective Date: April 23, 2009 Revised: February 2, 2021 Next Revision: February, 2022

This policy applies to products subscribed by the following corporations, MCS Life Insurance Company (Commercial), and MCS Advantage, Inc. (Classicare) and Medical Card System, Inc., provider’s contract; unless specific contract limitations, exclusions or exceptions apply. Please refer to the member’s benefit certification language for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply subject to the aforementioned exceptions. DESCRIPTION

Breast Reduction , also known as Reduction Mammaplasty, is a surgical procedure to remove excess fat, glandular tissue and , in order to achieve a breast size in proportion with the and to alleviate the discomfort associated with overly large . The justification for reduction mammaplasty should be based on the probability of relieving the clinical signs and symptoms of symptomatic breast . Symptomatic is defined as a syndrome of persistent neck and shoulder pain, painful shoulder grooving from brassiere straps, chronic intertriginous of the inframammary fold, and frequent episodes of , backache, and neuropathies caused by an increase in the volume and weight of breast tissue beyond normal proportions. Because it is difficult to determine the size at which breast enlargement becomes pathologic in any individual, the position of the American Society of Plastic Surgeons is that the definition of symptomatic breast hypertrophy should focus on the degree of symptomatology, not the degree of breast hypertrophy present (cup size or amount of tissue removed). (ASPS, 2017).

Breasts are pair organs and breast hypertrophy  when present  generally affects both sides. Therefore, when surgery is needed it is usually performed bilaterally. However, unilateral surgery may be performed if medically reasonable and necessary (CMS L33939, 2019).

The appropriate surgical approach should be determined by the physician and patient in accordance with the patient’s clinical situation. Considering that reduction mammaplasty may be used for both medically necessary and cosmetic indications, MCS has set the criteria below to distinguish medically necessary reduction mammaplasty from cosmetic reduction mammaplasty.

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate member certificate and subscriber agreement contract for applicable diagnostic imaging, DME, laboratory, machine tests, benefits and coverage.

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 1 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 1 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division

INDICATIONS

Medical Card System, Inc. (MCS) will consider Reduction Mammaplasty medically necessary when indications below, 1 plus 2; or 3 are met:

1. Performed in the presence of macromastia/breast hypertrophy and have documented symptoms that involve two (2) anatomic areas of the body and the condition must adversely affect activities of daily living, (ADLs), for at least one (1) year.

a. Signs and symptoms will include:

i. History of back, neck and shoulder pain, cervicalgia and torticollis;

ii. Ulnar paresthesias (Evidenced by a Conduction Studies);

iii. Acquired documented by x-rays;

iv. Intertrigonous maceration or of the inframammary (e.g., bleeding, hyperpigmentation, chronic moisture, evidence of skin breakdown), skin refractory to dermatologic measures.

v. Shoulder grooving with skin irritation (e.g., areas of excoriation and breakdown) by supporting garment.

vi. History of significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity.

2. A history of documented persistent pain symptoms, despite an attempted trial period of at least three (3) months of therapeutic measures, such as:

a. Supportive devices (e.g., such as garments, back brace, etc.,);

b. Conservative analgesic and non-steroidal anti-inflammatory drugs (NSAIDs) interventions;

c. Compresses, massage;

d. , and/or

e. Correction of .

3. Reconstruction of the affected and the contralateral unaffected breast following a medically necessary is considered a relatively safe and effective noncosmetic procedure.

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 2 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 2 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division Accordingly, program payment may be made for surgery following removal of a breast for any medical reason. (For more information regarding coverage criteria under this scenario, please refer to medical policy MP-SU-02-10 - Breast Reconstruction Following Mastectomy or .

Note1: Submission of pre-operative photographs is not required unless a specific request is made. Photographs should demonstrate the implication that supports the reduction mammaplasty procedure. Providers should maintain photographs in the and make them available upon request.

CONTRAINDICATIONS/LIMITATIONS

Medical Card System, Inc. (MCS) does NOT consider Reduction Mammaplasty medically necessary in ANY of the following criteria:

1. Individuals under the age of 18 years,

2. Reduction mammaplasty performed solely for improvement of aesthetic appearance without signs and symptoms of functional abnormality affecting activities of daily living (ADL’s).

3. Surgery solely being performed to treat psychological symptomatology or psychosocial complaints.

4. MCS contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.

CODING INFORMATION CPT® Codes (List may not be all inclusive) CPT® Codes DESCRIPTION 19318 Reduction mammaplasty 2020 Current Procedural Terminology (CPT®) Professional Edition. American Medical Association: Chicago, IL.

Note2: To report bilateral procedure, report modifier 50 with the procedure code. (AMA CPT® Professional Edition, 2020).

Note3: Modifier -LT should be used for left . Modifier -RT should be used for right breast reduction (AMA, HCPCS Level II Professional, 2020).

ICD-10 Codes (List may not be all inclusive) ICD-10-Codes DESCRIPTION L26 Exfoliative dermatitis L30.4 Erythema intertrigo L53.8 Other specified erythematous conditions L54 Erythema in diseases classified elsewhere

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 3 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 3 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division L92.0 Granuloma annulare L95.1 Erythema elevatum diutinum L98.2 Febrile neutrophilic dermatosis [Sweet] M25.511 Pain in right shoulder M25.512 Pain in left shoulder M25.519 Pain in unspecified shoulder M40.00 Postural kyphosis, site unspecified M40.03 Postural kyphosis, cervicothoracic region M40.04 Postural kyphosis, thoracic region M40.05 Postural kyphosis, thoracolumbar region M40.14 Other secondary kyphosis, thoracic region M40.202 Unspecified kyphosis, cervical region M40.203 Unspecified kyphosis, cervicothoracic region M40.204 Unspecified kyphosis, thoracic region M40.205 Unspecified kyphosis, thoracolumbar region M40.209 Unspecified kyphosis, site unspecified M40.294 Other kyphosis, thoracic region M43.6 Torticollis M53.82 Other specified dorsopathies, cervical region M54.2 Cervicalgia M54.6 Pain in thoracic spine M54.89 Other dorsalgia M54.9 Dorsalgia, unspecified M95.4 Acquired deformity of chest and rib N62 Hypertrophy of breast N64.2 Atrophy of breast N64.4 Mastodynia Q83.0 Congenital absence of breast with absent Q83.8 Other congenital malformations of breast R20.0 of skin R20.1 Hypoesthesia of skin R20.2 Paresthesia of skin R20.3 Hyperesthesia R20.8 Other disturbances of skin sensation R20.9 Unspecified disturbances of skin sensation R21 Rash and other nonspecific skin eruption R29.5 Transient paralysis

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 4 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 4 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division R51 Headache Z42.1 Encounter for breast reconstruction following mastectomy Z42.8 Encounter for other plastic and reconstructive surgery following medical procedure or healed injury Z85.3 Personal history of malignant of breast

REFERENCES

1. American Society of Plastic Surgeons (ASPS) (2021). Breast Reduction - Reduction Mammaplasty: What is breast reduction surgery? Accessed February 1, 2021. Available at URL Address: https://www.plasticsurgery.org/reconstructive-procedures/breast-reduction

2. American Society of Plastic Surgeons (ASPS) (2021). for Teenagers Briefing Paper. Accessed February 1, 2021. Available URL address: https://www.plasticsurgery.org/news/briefing-papers/briefing-paper-plastic-surgery-for- teenagers

3. American Society of Plastic Surgeons (ASPS) (2011). Evidence-based Clinical Practice Guideline: Reduction Mammaplasty. Accessed February 1, 2021. Available URL address: https://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence- practice/Reduction_Mammaplasty_Evidence_Based_Guideline%20(2)(2).pdf

4. American Society of Plastic Surgeons (ASPS) (2011, May). Reduction Mammaplasty: ASPS Recommended Insurance Coverage Criteria for Third-Party Payers. Approved by the Executive Committee of the American Society of Plastic Surgeons®. Reaffirmed: October 2017. ICD-10-CM Coding Updated January 2016. Accessed February 1, 2021. Available URL address: https://www.plasticsurgery.org/Documents/Health-Policy/Reimbursement/insurance-2017- reduction-mammaplasty.pdf

5. Centers for Medicare & Medicaid Services (CMS). (2018). Local Coverage Article: Reduction mammaplasty revision to the Part B LCD (A57538). Original Article Effective Date: 10/03/2018. Revision Effective Date: 01/01/2021. Accessed February 16, 2021. Available URL address: https://www.cms.gov/medicare-coverage-database/details/article- details.aspx?articleId=57538&ver=6&LCDId=33939&DocID=L33939&bc=gAAAAAgAkAAA&

6. Centers for Medicare & Medicaid Services (CMS). (2019). Local Coverage Determination (LCD) for Reduction Mammaplasty (L33939). Contractor Name: First Coast Service Options. Primary Geographic Jurisdiction: Puerto Rico. Original Determination Effective Date: 10/01/2015. Revision Effective Date: For services performed on or after 01/08/2019. Accessed February 1, 2021. Available URL address: https://www.cms.gov/medicare-coverage-database/details/lcd- details.aspx?LCDId=33939&ver=11&articleId=57538&DocID=L33939&bc=gAAAAAgAkAAA&

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 5 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 5 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division 7. Mayo Foundation for Medical Education and Research (MayoClinic). (2021). Breast reduction surgery. Accessed February 1, 2021. Available URL address: https://www.mayoclinic.org/tests- procedures/breast-reduction-surgery/basics/results/prc-20021706?p=1

8. UpToDate®/ Hansen, J. & Chang, S. (2020). Overview of breast reduction. Last updated: January 14, 2020. Accessed February 1, 2021. Available at URL address: https://www.uptodate.com/contents/overview-of-breast- reduction?source=search_result&search=reduction+mammoplasty&selectedTitle=1~79

9. UpToDate®/ Braunstein, G. (2021). Management of . Last updated: January 21, 2019. Accessed February 1, 2021. Available URL address: https://www.uptodate.com/contents/management-of- gynecomastia?source=search_result&search=Breast%20Reduction%20Surgery&selectedTitle=2~ 18

POLICY HISTORY DATE ACTION COMMENT

April 23, 2009 Origination of Policy April 22, 2010 Revised I. Policy coverage only for MCS Life Commercial and MCS HMO line of business (LOB). II. For MCS Advantage Classicare coverage follow CMS first coast options LCD L29384. June 8, 2011 Yearly Revision April 27, 2012 Yearly Revision References updated. ICD9 code 782.0 added to policy. ICD9 611.4 deleted.

April 25, 2013 Revised References updated.

To Coding Information: Added ICD-9 Code 611.4.

July 31, 2013 Revised References updated. Added new references: numbers 1 & 5.

To Coding Information added Notes 2 & 3.

February 21,2014 Revised To the Coding section: A new ICD-10 Codes (Preview Draft) section was added to the policy.

June 6, 2014 Revised References updated. Added new references: numbers 1-2, 6, & 8.

To the Description Section:  Added the corresponding citations: (CMS L29384, 2009).  Deleted: Breast reduction surgery, or reduction mammaplasty, involves the removal of fat, glandular tissue, and skin from the breasts. Breast reduction is usually performed to relief from orthopedic, neurologic, dermatologic, and/or respiratory symptoms caused by excessively large breasts (macromastia in the female breast and gynecomastia in the male ) rather than for cosmetic improvement. Medically indicated symptoms for breast reconstruction include postural backache, upper back and neck pain, and ulnar paresthesia. Physical findings that may be found are: shoulder grooving from straps, intertrigo (dermatitis occurring between folds or juxtaposed surfaces of the skin and

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 6 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 6 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division caused by sweat retention, moisture, warmth, and the overgrowth of resident microorganisms), , poor posture, and the inability to participate in normal physical activities.  Also deleted: The objectives of breast reduction surgery include relieving the above-mentioned symptoms caused by breast hypertrophy by reducing breast size, while preserving nipple sensation, maintaining the breasts nursing capacity, and constructing a breast that clinicians will be able to examine for possible breast masses in the future.  Added: Breast reduction surgery, also known as Reduction Mammaplasty, is a type of surgery that removes excess breast fat, glandular tissue and skin, in order to achieve a breast size in proportion with your body and to alleviate the discomfort associated with overly large breasts (ASPS, 2014).

To the Indications Section:  To Indication 1 added a. Signs & Symptoms = v. Shoulder grooving with skin irritation (e.g., areas of excoriation and breakdown) by supporting garment.  To Indication 2 modification was made to read as it follows: A history of documented persistent pain symptoms, despite an attempted trial period of at least three (3) months of therapeutic measures.  To Indication #3 added to parenthesis the phrase: available at the following URL address: https://www.mcs.com.pr/es/proveedores/Paginas/politicasMedicas .aspx.

To the Limitations Section:  Added the corresponding citations: (ASPS, 2014); (ASPS, 2011); & (ASPS, n.d.).

To the Coding Information:  Added new ICD-9 Codes: 723.9, 738.3, & 784.0.  To Note 1 added corresponding citation: (CMS L29384, 2009).  From Note 2 deleted: The appropriate modifier should be used to identify if the procedure performed is a bilaterial or unilaterial reduction. Modifier –50 should be used for bilateral reduction.  To Note 2 added: To report bilateral procedure, report modifier -50 with procedure code (AMA CPT®, 2014).  Added Note 3: Modifier -LT should be used for left breast reduction. Modifier -RT should be used for right breast reduction (AMA HCPCS, 2014).  Deleted Note: Use ICD-9-CM V51.8 as the primary diagnosis when submitting for reduction mammaplasty performed following a medically necessary procedure on the contralateral breast.

October 29, 2015 Revised References updated.

To the Description Section: In the second paragraph; Phrase “Your Body” was deleted and substituted by the new Phrase “Human Body”.

To the Indications Section:  Words "Hyperpigmentation and Chronic Moisture" were added from the LCD (L33939) to the Indication 1.a.iv.  New indication 2.c. “Compresses and Massage” were added to the Policy.  New Note3 was added to the Policy from the LCD (L33939).

To the References Section: Ecri Institute Reference was deleted for the Policy.

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 7 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 7 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division

June 23, 2016 Revised. References updated. Added new reference # 7.

To the Description Section:  Moved 2nd paragraph to the opening of this section.  To the new 1st paragraph: Deleted phrase “type of surgery that removes” and replaced with: “surgical procedure to remove”.  To the new 1st paragraph: Added sentences “The justification for reduction mammaplasty should be based on the probability of relieving the clinical signs and symptoms of symptomatic breast hypertrophy. Symptomatic breast hypertrophy is defined as a syndrome of persistent neck and shoulder pain, painful shoulder grooving from brassiere straps, chronic intertriginous rash of the inframammary fold, and frequent episodes of headache, backache, and neuropathies caused by an increase in the volume and weight of breast tissue beyond normal proportions. Because it is difficult to determine the size at which breast enlargement becomes pathologic in any individual, the position of the American Society of Plastic Surgeons is that the definition of symptomatic breast hypertrophy should focus on the degree of symptomatology, not the degree of breast hypertrophy present (cup size or amount of tissue removed).  To the 3rd paragraph: replaced word “Because” with “Considering that.”

To the Indications Section:  Renumbered former note #3 as note #1.  To #3: Embedded URL Address into the related medical policy’s title while removing its manual retrieval information.

To the Contraindications/Limitations Section:  To #1: Deleted citation.  To #3: Added word “solely” and removed “is”. Deleted citation.

To the Coding Section:  To the ICD-10 table: Deleted “(Preview Draft)” from title and “In preparation for changes in the coding systems form ICD- 9 to ICD - 10, this policy includes a sample list of ICD-10 codes for your reference. These codes may become subject to changes or modifications since they will be in effect on October 1, 2015.”  Renumbered former notes #1 and #2, to #2 and #3.  Added new ICD-10 codes: M40.14, M40.294, Q83.0, Q83.1, Q83.8, Q83.9.

November 09, 2017 Revised. To the Coding Information:  To the Note#2: Wording for Note#2 was corrected according to CPT 2018 - Bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code (AMA CPT® Professional, 2018).

 To the ICD-10 Codes Section: o ICD-10 Codes (G44.1, M99.82, and M99.88) were deleted from this Policy.

o New ICD-10 Code Z42.1 was added to the Policy.

February 8, 2019 Revised. To the Indications Section:  To the Subsection 1a. - iv: Words “and, candidiasis and/or antibiotics” were deleted from 1a. - iv and word “or” was added after the review with the LCD L33939.

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 8 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 8 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division  New “Signs and symptoms” VI was added to the Policy from LCD L33939.

 Information was deleted and substitute by the new one: Reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is considered a relatively safe and effective noncosmetic procedure. Accordingly, program payment may be made for breast reconstruction surgery following removal of a breast for any medical reason. Reduction Mammaplasty is also indicated to achieve symmetry following removal and/or reconstruction of a breast due to malignancy.

To the Coding Information:  To the ICD-10 Section: The following ICD-10 Section was deleted from this Policy: Q83.1.

To the References Section:  The following Reference was added to the Policy: #5. February 24, 2020 Revised. To the Contraindications/Limitations Section:  New Contraindication/Limitation #4 was added to the Policy: MCS Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.

To the Coding Information Section:  Note2 was reviewed and adapted to the information contained in the (AMA CPT® Professional Edition, 2020): Bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate 5-digit code To report bilateral procedure, report modifier 50 with the procedure code. (AMA CPT® Professional Edition, 2020).

 To the ICD-10 Codes Section: The following ICD-10 Code was deleted from this Policy: Q83.9. February 2, 2021 Revised References updated

This document is for informational purposes only. It is not an authorization, certification, explanation of benefits, or contract. Receipt of benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with the terms of the member’s plan in effect as of the date services are rendered. Medical Card System, Inc., (MCS) medical policies are developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, Medical Card System, Inc., (MCS) reserves the right to review and update its medical policies at its discretion. Medical Card System, Inc., (MCS) medical policies are intended to serve as a resource to the plan. They are not intended to limit the plan’s ability to interpret plan language as deemed appropriate. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment they choose to provide.

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 9 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 9 All Rights Reserved®