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Medical Necessity Criteria for Reduction Mammoplasty

Approved:  2/16/01                
Reviewed 3/02, 6/04, 8/04, 3/06, 2/07, 3/10, 2/11, 1/12, 1/13, 3/14, 1/15, 1/16, 1/17
Revised:  3/02, 6/04, 8/04, 3/06, 6/07, 2/08, 1/09, 3/14, 1/15
 
Reduction mammoplasty is generally performed to relieve symptoms related to the heaviness and size of the breasts.  Because reduction mammoplasty may be performed for both medically necessary and cosmetic reasons, the medical need for this procedure must be established by documenting that the enrollee has significant symptoms or functional impairments that cannot be adequately managed with more conservative, less invasive measures.  The following guidelines are used when considering the medical necessity of reduction mammoplasty requests:
  1. The patient is at least 18 years of age or older or for whom growth is complete (ie, breast size stable over one year).
  2. Persistent symptoms include at least two (2) of the following:
    1. severe and chronic bra strap grooving
    2. upper extremity parathesias unresponsive to conservative treatments
    3. back, neck, or shoulder pain unresponsive to conservative measures
    4. intertrigo unresponsive to adequate treatment regimens
    5. breathing difficulties attributed to excess breast mass and documented by spirometric testing
    6. Chronic breast pain due to weight of the breasts
    7. Thoracic kyphosis, acquired
    8. Headache
    9. Congenital breast deformity
  3. A breast exam within the past six (6) months indicating that there are no contraindications for breast reduction surgery.
  4. A mammogram within the past twelve (12) months noting no contraindications for breast reduction surgery is required for patients older than 40 years.
  5. Photographs.

ConnectCare

Utilization Management

ConnectCare's Utilization Management Staff is available to address questions and issues related to case management and utilization by using the telephone or fax numbers listed below.

ConnectCare Medical Management
4000 Wellness Drive
Midland, MI 48670
Toll free: 888-646-2429
Local: 989-839-1613
Fax: 989-839-1679
 
Hours of Operation
8:00 a.m. - 12:00 p.m.
1:00 p.m. - 5:00 p.m.
Monday - Friday (Eastern Time)

After normal business hours, inbound communications and information may be relayed via fax, confidential voice mail or electronic mail. All precertification requests and/or communications received after normal business hours are returned on the next business day and communications received after midnight on Monday through Friday are responded to on the same business day.