Clinical Medical Policy Department Clinical Affairs Division Reduction Mammaplasty [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 Surgery, also known as Reduction Mammaplasty, is a surgical procedure to remove excess breast fat, glandular tissue and skin, in order to achieve a breast size in proportion with the human body and to alleviate the discomfort associated with overly large breasts. 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). (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 Nerve Conduction Studies); iii. Acquired kyphosis documented by x-rays; iv. Intertrigonous maceration or infection 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. Physical therapy, and/or e. Correction of obesity. 3. Reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy 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 breast reconstruction 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 Lumpectomy. 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 medical record 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 breast reduction. 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 nipple Q83.8 Other congenital malformations of breast R20.0 Anesthesia 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