Macromastia or gigantomastia is an ill-defined term that describes breast hyperplasia or hypertrophy. Macromastia may result in clinical symptoms such as shoulder, neck, or back pain, or recurrent intertrigo in the mammary folds. In addition, macromastia may be associated with psychosocial or emotional disturbances related to the large breast size. Reduction mammaplasty is a surgical procedure designed to remove a variable proportion of breast tissue to address emotional and psychosocial issues and/or relieve the associated clinical symptoms.

Reduction mammaplasty may be considered medically necessary for the treatment of macromastia when well-documented clinical symptoms are present, including but not limited to:

• Documentation of a minimum 6-week history of shoulder, neck, or back pain related to macromastia that is not responsive to conservative therapy, such as an appropriate support bra, exercises, heat/cold treatment, and appropriate non-steroidal anti-inflammatory agents/muscle relaxants
• Intertrigo between the pendulous breast and the chest wall.

The presence of shoulder, neck, or back pain is the most common stated medical rationale for reduction mammaplasty. However, since this symptom is entirely subjective, Blue Cross of Idaho uses the following patient selection criteria designed to be more objective in nature. These have included:

• Use of photographs, providing a visual documentation of breast size, or documenting the presence of shoulder grooving, an indication that the breast weight results in grooving of the bra straps on the shoulder.
• Requirement of a specified amount of breast tissue to be resected, commonly 500–600 g per breast
• Use of the Schnur sliding scale, which suggests a minimum amount of breast tissue to be removed for the procedure to be considered medically necessary, based on the patient’s body surface area. (See Rationale section for further discussion.) (Some plans may use the Schnur sliding scale only for weight of resected tissue that falls below 500–600 g.)
• Consider that patients who are not within 20% of ideal body weight may have obesity that is contributing to the symptoms of neck and back pain.

BlueCard/National Account Issues

Medical policies regarding reduction mammaplasty have focused on the distinction between a cosmetic procedure, performed primarily to improve the appearance of the breast, or a medically necessary procedure, performed primarily to relieve documented clinical symptoms. It should be noted that the emotional and psychosocial distress associated with body appearance does not constitute a medical rationale for reduction mammaplasty, and thus these indications would be considered cosmetic in nature.

A search of the literature based on the MEDLINE database was performed for the period of 1995 to September 2003. While the literature search identified several articles that discuss the surgical technique of reduction mammaplasty and document that reduction mammaplasty is associated with a relief of physical and psychosocial symptoms (1-5), the medical policy has always focused on the distinction of whether the proposed reduction mammaplasty is medically necessary or cosmetic in nature. For some patients the presence of medical indications is clear-cut, i.e., a clear documentation of recurrent intertrigo, or ulceration secondary to shoulder grooving. However, for the majority of patients, the documentation between a cosmetic and medically necessary procedure will be unclear and subjective in nature. Criteria for medically necessary reduction mammaplasty are not well addressed in the published medical literature, and thus the optimal patient selection criteria cannot rely on an evidence-based approach. Therefore, the policy guidelines do not endorse a particular set of patient selection criteria, i.e. the use of photographs, amount of breast tissue removed, or a combination of approaches.

The following discussion focuses the published literature addressing the use of weight of excised breast as coverage criteria. In 2001, Krieger and colleagues reported on a survey of managed care policies regarding reduction mammaplasty. (6) Most of the respondents to the survey stated that they use weight of excised tissue as the main criterion for allowing the procedure. The average cut-off value for this determination was 472 g. While 500 g. appears to be a commonly sited cut-off weight of excised tissue, there appears to be no documentation in the literature as to the sensitivity and specificity of this value in distinguishing cosmetic from medically necessary procedures. (7) Also, the use of a single weight cut-off does not address the issue of the relationship between body surface area and weight of excised tissue. In 1991, Schnur and colleagues, at the request of third-party payers, developed a sliding scale. (7) This sliding scale was based on survey responses of 92 of 200 solicited plastic surgeons, who reported the height, weight, and amount of breast tissue removed from each breast from the last 15 to 20 reduction mammaplasties that had been performed. The surgeons were also asked if the procedures were performed for cosmetic or medically necessary reasons. The data were then used to create a chart relating the body surface area and the cutoff weight of breast tissue removed according to the 5th percentile and 22nd percentile lines. Based on their estimates, those with breast weight above the 22nd percentile line likely had the procedure performed for medical reasons, while those below the 5 percentile line likely had the procedure performed for cosmetic reasons, and those falling between the lines had the procedure formed for mixed reasons. (See Appendix for the Schnur Sliding Scale.)

In 1999, Schnur reviewed the experience of the sliding scale as a coverage criterion, and reported that while many payers had adopted this scale, many had also misused it. (8) The author pointed out that if a payer uses weight of resected tissue as a coverage criteria, then if the weight falls below the 5th percentile line the reduction mammaplasty would be considered cosmetic, above the 22nd percentile line would be considered medically necessary, and those that fell between these lines would be considered on a case by case basis. The author also questions the frequent requirement that a woman be within 20% of her ideal body weight. While weight loss might indeed relieve symptoms, durable weight loss is notoriously difficult and may be unrealistic in many cases.

In 2002, Kerrigan and Collins published the results of the BRAVO (Breast Reduction: Assessment of Value and Outcomes) study, a registry of 179 women undergoing reduction mammaplasty. (9) Women were asked to complete quality of life questionnaires and a physical symptom count both before and after surgery. The physical symptom count focused on the number of symptoms present that were specific to breast hypertrophy and included upper back pain, rashes, bra strap grooves, neck pain, shoulder pain, numbness and arm pain. In addition, the weight and volume of resected tissue were recorded. Results were compared to a control group of patients with breast hypertrophy, defined as size DD bra cup, and normal sized breasts, who were recruited from the general population. The authors propose that the presence of 2 physical symptoms might be an appropriate cut-off for determining medical necessity for breast reduction. For example, while 71.6% of the hypertrophic controls reported none or one symptom, only 12.4% of those considered surgical candidates reported none or one symptom. This observation is difficult to evaluate because the study does not report how surgical candidacy was determined. The authors also reported that none of the traditional criteria for determining medical necessity for breast reduction surgery (height, weight, body mass index, bra cup size, or weight of resected breast tissue) had a statistically significant relationship with outcome improvement. The authors conclude that the determination of medical necessity should be based on patients’ self reports of symptoms rather than more objectively measured criteria, such as weight of excised breast tissue.

References:

1. Dabbah A, Lehman JA, Parker MG et al. Reduction mammaplasty: an outcome analysis. Ann Plast Surg 1995; 35(4):337-41.
2. Schnur PL, Schnur DP, Petty PM et al. Reduction mammaplasty: an outcome study. Plast Reconstr Surg 1997; 100(4):875-83.
3. Hidalgo DA, Elliot LF, Palumbo S et al. Current trends in breast reduction. Plast Reconstr Surg 1999; 104(3):806-18.
4. Glatt BS, Sarwer DB, O’Hara DE et al. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Plast Reconstr Surg 1999; 103(1):76-85.
5. Collins ED, Kerrigan CL, Kim M et al. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plast Reconstr Surg 2002; 109(5):1556-66.
6. Krieger LM, Lesavoy MA. Managed care’s methods for determining coverage of plastic surgery procedures: the example of reduction mammaplasty. Plast Reconstr Surg 2001; 107(5):1234-40.
7. Schnur PL, Hoehn JG, Ilstrup DM et al. Reduction mammaplasty: cosmetic or reconstructive procedure? Ann Plast Surg 1991; 27(3):232-7.
8. Schnur PL. Reduction mammaplasty – the Schnur Sliding Scale revisited. Ann Plast Surg 1999; 42(1):107-8.
9. Kerrigan CL, Collins ED, Kim HM et al. Reduction mammaplasty: defining medical necessity. Med Decis Making 2002; 22(3):208-17.

Breast reduction
Reduction mammaplasty

*Calculation of Body Surface AreaBody surface area = the square root of height (cm) times weight (kg) divided by 3600To convert pounds to kilograms, multiply pounds by 0.45To convert inches to meters, multiply inches by .0254