Aetna Breast Reduction Surgery coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• GATE — Eligible population: Aetna considers breast reduction surgery medically necessary for non-cosmetic indications for women aged 18 or older OR for whom growth is complete (i.e., breast size stable over one year). Coverage requires meeting ANY ONE of: Criterion A (Macromastia), Criterion B (Gigantomastia of pregnancy), or Criterion C (Asymmetry — see CPB 0185).
• CRITERION A (Macromastia) — must meet ALL of the following sub-requirements (symptom requirement + all additional requirements 1-6).
• Criterion A, Symptom requirement: Member has persistent symptoms in at least TWO (ONE of: at least two) of these anatomical body areas, directly attributed to macromastia and affecting daily activities for at least 1 year — (TWO or more of): Headaches; Pain in neck; Pain in shoulders; Pain in upper back; Painful kyphosis documented by X-rays; Pain/discomfort/ulceration from bra straps cutting into shoulders; Skin breakdown (severe soft tissue infection, tissue necrosis, ulceration, hemorrhage) from overlying breast tissue; Upper extremity paresthesia.
• Criterion A, Additional requirement 1 (Severe breast hypertrophy): Member has severe breast hypertrophy, documented by high-quality color frontal-view and side-view photographs.
• Criterion A, Additional requirement 2 (Causal relationship): There is a reasonable likelihood that the member's symptoms are primarily due to macromastia.
• Criterion A, Additional requirement 3 (Likelihood of benefit): Reduction mammoplasty is likely to result in improvement of the chronic pain.
• Criterion A, Additional requirement 4 (Conservative treatment trial): Pain symptoms persist as documented by the physician despite at least a 3-month trial of therapeutic measures such as (examples include): Analgesic/non-steroidal anti-inflammatory drugs (NSAIDs) interventions and/or muscle relaxants; Dermatologic therapy of ulcers, necrosis and refractory infection; Physical therapy/exercises/posturing maneuvers; Supportive devices (e.g., proper bra support, wide bra straps); Chiropractic care or osteopathic manipulative treatment; Medically supervised weight loss program; Orthopedic or spine surgeon evaluation of spinal pain.
• Criterion A, Additional requirement 5 (Mammogram for age 50+): Women 50 years of age or older are required to have a mammogram that was negative for cancer performed within the two years prior to the date of the planned reduction mammoplasty.
• Criterion A, Additional requirement 6 (Tissue removal amount): The surgeon estimates that at least the threshold amount (in grams) of breast tissue, not fatty tissue, will be removed from each breast, based on the member's body surface area (BSA) calculated using the Mosteller formula (see Appendix Table 1). Mosteller formula: BSA (m2) = ([height (in) x weight (lb)]/3131)^(1/2), or BSA (m2) = ([height (cm) x weight (kg)]/3600)^(1/2).
• Criterion A, Tissue-removal EXCEPTION (BSA waived): Breast reduction surgery will be considered medically necessary for women meeting the symptomatic criteria specified above, REGARDLESS OF BSA, with more than 1 kg (>1000 grams) of breast tissue to be removed per breast.
• Criterion A, Intertrigo/dermatitis clarification: Chronic intertrigo, eczema, dermatitis, and/or ulceration in the infra-mammary fold may support medical necessity ONLY when it BOTH (a) is unresponsive to dermatological treatments (e.g., antibiotics or antifungal therapy) and conservative measures (e.g., good skin hygiene, adequate nutrition) for a period of 6 months or longer, AND (b) also satisfies the full Criterion A macromastia criteria above — these skin conditions in and of themselves are NOT a medically necessary indication.
• CRITERION B (Gigantomastia of pregnancy): The member has gigantomastia of pregnancy accompanied by ANY ONE of the following complications, AND delivery is not imminent — (ONE of): Massive infection; OR Significant hemorrhage; OR Tissue necrosis with slough; OR Ulceration of breast tissue.
• CRITERION C (Breast asymmetry): For medical necessity criteria for surgery to correct breast asymmetry, see CPB 0185 - Breast Reconstructive Surgery.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 19318·PA verdict·Rate

Documentation required

• High-quality color frontal-view and side-view photographs documenting severe breast hypertrophy.
• Physician documentation that pain symptoms persist despite at least a 3-month trial of conservative/therapeutic measures (the specific modalities itemized in the criteria).
• Physician documentation that symptoms are primarily due to macromastia and that reduction mammoplasty is likely to improve the chronic pain.
• X-ray documentation where painful kyphosis is relied upon as a qualifying symptom.
• For women 50 years of age or older: a mammogram negative for cancer performed within the two years prior to the planned reduction mammoplasty.
• Body Surface Area (BSA) calculation using the Mosteller formula to establish the minimum per-breast tissue-removal threshold (or documentation supporting the >1 kg per breast exception).
• Surgeon's estimate of the amount of breast tissue (not fatty tissue) to be removed from each breast.

Frequently asked questions

When does Aetna cover Breast Reduction Surgery (CPT 19318), and what gets it denied?

Aetna CPB 0017 covers breast reduction (reduction mammoplasty) as medically necessary only for symptomatic macromastia in women 18+ (or whose growth is complete) who have at least two qualifying physical symptoms for >=1 year, severe hypertrophy documented by photos, a failed >=3-month conservative-therapy trial, and a surgeon's estimate that the tissue removed per breast meets the BSA/Mosteller threshold (waived if >1 kg per breast) — plus a negative mammogram within 2 years for women 50+. Gigantomastia of pregnancy with serious complications is also covered. Gynecomastia surgery and any other/asymptomatic indication are deemed cosmetic and not covered, and several minimally invasive/liposuction-based and gynecomastia-related techniques are experimental/investigational. Coverage criteria include: GATE — Eligible population: Aetna considers breast reduction surgery medically necessary for non-cosmetic indications for women aged 18 or older OR for whom growth is complete (i.e., breast size stable over one year). Coverage requires meeting ANY ONE of: Criterion A (Macromastia), Criterion B (Gigantomastia of pregnancy), or Criterion C (Asymmetry — see CPB 0185).; CRITERION A (Macromastia) — must meet ALL of the following sub-requirements (symptom requirement + all additional requirements 1-6).; Criterion A, Symptom requirement: Member has persistent symptoms in at least TWO (ONE of: at least two) of these anatomical body areas, directly attributed to macromastia and affecting daily activities for at least 1 year — (TWO or more of): Headaches; Pain in neck; Pain in shoulders; Pain in upper back; Painful kyphosis documented by X-rays; Pain/discomfort/ulceration from bra straps cutting into shoulders; Skin breakdown (severe soft tissue infection, tissue necrosis, ulceration, hemorrhage) from overlying breast tissue; Upper extremity paresthesia.; Criterion A, Additional requirement 1 (Severe breast hypertrophy): Member has severe breast hypertrophy, documented by high-quality color frontal-view and side-view photographs.; Criterion A, Additional requirement 2 (Causal relationship): There is a reasonable likelihood that the member's symptoms are primarily due to macromastia.; Criterion A, Additional requirement 3 (Likelihood of benefit): Reduction mammoplasty is likely to result in improvement of the chronic pain.; Criterion A, Additional requirement 4 (Conservative treatment trial): Pain symptoms persist as documented by the physician despite at least a 3-month trial of therapeutic measures such as (examples include): Analgesic/non-steroidal anti-inflammatory drugs (NSAIDs) interventions and/or muscle relaxants; Dermatologic therapy of ulcers, necrosis and refractory infection; Physical therapy/exercises/posturing maneuvers; Supportive devices (e.g., proper bra support, wide bra straps); Chiropractic care or osteopathic manipulative treatment; Medically supervised weight loss program; Orthopedic or spine surgeon evaluation of spinal pain.; Criterion A, Additional requirement 5 (Mammogram for age 50+): Women 50 years of age or older are required to have a mammogram that was negative for cancer performed within the two years prior to the date of the planned reduction mammoplasty.; Criterion A, Additional requirement 6 (Tissue removal amount): The surgeon estimates that at least the threshold amount (in grams) of breast tissue, not fatty tissue, will be removed from each breast, based on the member's body surface area (BSA) calculated using the Mosteller formula (see Appendix Table 1). Mosteller formula: BSA (m2) = ([height (in) x weight (lb)]/3131)^(1/2), or BSA (m2) = ([height (cm) x weight (kg)]/3600)^(1/2).; Criterion A, Tissue-removal EXCEPTION (BSA waived): Breast reduction surgery will be considered medically necessary for women meeting the symptomatic criteria specified above, REGARDLESS OF BSA, with more than 1 kg (>1000 grams) of breast tissue to be removed per breast.; Criterion A, Intertrigo/dermatitis clarification: Chronic intertrigo, eczema, dermatitis, and/or ulceration in the infra-mammary fold may support medical necessity ONLY when it BOTH (a) is unresponsive to dermatological treatments (e.g., antibiotics or antifungal therapy) and conservative measures (e.g., good skin hygiene, adequate nutrition) for a period of 6 months or longer, AND (b) also satisfies the full Criterion A macromastia criteria above — these skin conditions in and of themselves are NOT a medically necessary indication.; CRITERION B (Gigantomastia of pregnancy): The member has gigantomastia of pregnancy accompanied by ANY ONE of the following complications, AND delivery is not imminent — (ONE of): Massive infection; OR Significant hemorrhage; OR Tissue necrosis with slough; OR Ulceration of breast tissue.; CRITERION C (Breast asymmetry): For medical necessity criteria for surgery to correct breast asymmetry, see CPB 0185 - Breast Reconstructive Surgery.. Applies to 1 code: 19318. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: High-quality color frontal-view and side-view photographs documenting severe breast hypertrophy.; Physician documentation that pain symptoms persist despite at least a 3-month trial of conservative/therapeutic measures (the specific modalities itemized in the criteria).; Physician documentation that symptoms are primarily due to macromastia and that reduction mammoplasty is likely to improve the chronic pain.; X-ray documentation where painful kyphosis is relied upon as a qualifying symptom.; For women 50 years of age or older: a mammogram negative for cancer performed within the two years prior to the planned reduction mammoplasty.; Body Surface Area (BSA) calculation using the Mosteller formula to establish the minimum per-breast tissue-removal threshold (or documentation supporting the >1 kg per breast exception).; Surgeon's estimate of the amount of breast tissue (not fatty tissue) to be removed from each breast. Policy exclusions and limitations: COSMETIC (not covered) — Breast reduction surgery is considered cosmetic for ALL indications not listed in the Medical Necessity section for Macromastia.; COSMETIC (not covered) — Reduction mammoplasty for asymptomatic members is considered cosmetic.; COSMETIC (not covered) — Gynecomastia: Aetna considers breast reduction, surgical mastectomy or liposuction for gynecomastia, either unilateral or bilateral, a cosmetic surgical procedure. Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance). Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia.; NOT MEDICALLY NECESSARY (in and of themselves) — Chronic intertrigo, eczema, dermatitis, and/or ulceration in the infra-mammary fold are not considered medically necessary indications for reduction mammoplasty by themselves (unless the unresponsive-for-6-months AND full-macromastia-criteria conditions are met).; EXPERIMENTAL, INVESTIGATIONAL, OR UNPROVEN (insufficient evidence of effectiveness) — Air-assisted, nipple-areola-sparing mastectomy and liposuction.; EXPERIMENTAL, INVESTIGATIONAL, OR UNPROVEN — Combined arthroscopic shaver and liposuction for the treatment of adolescent gynecomastia.; EXPERIMENTAL, INVESTIGATIONAL, OR UNPROVEN — Liposuction and peri-areolar excision under tumescent local anesthesia.; EXPERIMENTAL, INVESTIGATIONAL, OR UNPROVEN — Liposuction-only reduction mammoplasty.; EXPERIMENTAL, INVESTIGATIONAL, OR UNPROVEN — Mastoscopic subcutaneous mastectomy.; EXPERIMENTAL, INVESTIGATIONAL, OR UNPROVEN — Radiotherapy (for the prevention or management of gynecomastia recurrence).; EXPERIMENTAL, INVESTIGATIONAL, OR UNPROVEN — Vacuum-assisted breast biopsy system for treatment of gynecomastia. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Does Aetna require prior authorization for Breast Reduction Surgery?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: High-quality color frontal-view and side-view photographs documenting severe breast hypertrophy.; Physician documentation that pain symptoms persist despite at least a 3-month trial of conservative/therapeutic measures (the specific modalities itemized in the criteria).; Physician documentation that symptoms are primarily due to macromastia and that reduction mammoplasty is likely to improve the chronic pain.; X-ray documentation where painful kyphosis is relied upon as a qualifying symptom.; For women 50 years of age or older: a mammogram negative for cancer performed within the two years prior to the planned reduction mammoplasty.; Body Surface Area (BSA) calculation using the Mosteller formula to establish the minimum per-breast tissue-removal threshold (or documentation supporting the >1 kg per breast exception).; Surgeon's estimate of the amount of breast tissue (not fatty tissue) to be removed from each breast.

What does Aetna exclude for Breast Reduction Surgery?

Policy exclusions and limitations: COSMETIC (not covered) — Breast reduction surgery is considered cosmetic for ALL indications not listed in the Medical Necessity section for Macromastia.; COSMETIC (not covered) — Reduction mammoplasty for asymptomatic members is considered cosmetic.; COSMETIC (not covered) — Gynecomastia: Aetna considers breast reduction, surgical mastectomy or liposuction for gynecomastia, either unilateral or bilateral, a cosmetic surgical procedure. Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance). Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia.; NOT MEDICALLY NECESSARY (in and of themselves) — Chronic intertrigo, eczema, dermatitis, and/or ulceration in the infra-mammary fold are not considered medically necessary indications for reduction mammoplasty by themselves (unless the unresponsive-for-6-months AND full-macromastia-criteria conditions are met).; EXPERIMENTAL, INVESTIGATIONAL, OR UNPROVEN (insufficient evidence of effectiveness) — Air-assisted, nipple-areola-sparing mastectomy and liposuction.; EXPERIMENTAL, INVESTIGATIONAL, OR UNPROVEN — Combined arthroscopic shaver and liposuction for the treatment of adolescent gynecomastia.; EXPERIMENTAL, INVESTIGATIONAL, OR UNPROVEN — Liposuction and peri-areolar excision under tumescent local anesthesia.; EXPERIMENTAL, INVESTIGATIONAL, OR UNPROVEN — Liposuction-only reduction mammoplasty.; EXPERIMENTAL, INVESTIGATIONAL, OR UNPROVEN — Mastoscopic subcutaneous mastectomy.; EXPERIMENTAL, INVESTIGATIONAL, OR UNPROVEN — Radiotherapy (for the prevention or management of gynecomastia recurrence).; EXPERIMENTAL, INVESTIGATIONAL, OR UNPROVEN — Vacuum-assisted breast biopsy system for treatment of gynecomastia. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT