Guidelines for Medical Necessity Determination for Breast Reduction

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caused by excessive breast tissue. Women presenting various forms of breast hypertrophy (for example, macromastia or gigantomastia of pregnancy) accompanied by persistent clinical signs and symptoms that adversely affect health are the principal candidates for breast reduction. Section II. Clinical Guidelines MassHealth bases its determination of medical necessity for breast reduction on a combination of clinical data and the presence of indicators that would affect the relative risks and benefits of the procedure, including post- operative recovery. These include, but are not limited to, the following. A. A comprehensive medical history and physical exam has been conducted by a physician to evaluate the need for breast reduction. B. A surgical treatment plan that outlines the amount of tissue to be removed from each breast and the prognosis for improvement of clinical signs/symptoms pertinent to the diagnosis has been developed. C. The member is female and generally over 18 years of age presenting symptoms described in Section II.D of these Guidelines. Guidelines for Medical Necessity Determination for Breast Reduction 2 D. Female breast hypertrophy is accompanied by symptoms of persistent pain in the back, neck, and/or shoulders, and/or intractable cervicodorsal myositis, and may or may not include tissue necrosis or ulcerations of the inframammary fold unresponsive to nonsurgical treatments. E. Comorbid etiologies of the symptoms have been considered and ruled out. Section III. Submitting Clinical Documentation A. Requests for prior authorization for breast reduction must be accompanied by clinical documentation that supports the medical necessity for this procedure. B. Documentation of medical necessity must include all the following: 1. the primary diagnosis name and ICD-9-CM codes pertinent to clinical symptoms; 2. the secondary diagnosis name(s) and ICD-9-CM code(s) pertinent to comorbid condition(s); 3. the most recent medical evaluation, including a summary of the medical history and last physical exam, including the member 9s age at onset of the condition, duration of the condition, date the member was diagnosed with the condition, the member 9s current age, comorbid condition(s), and all previous surgeries and hospitalizations; 4. prior treatments that have been tried and have not been effective in managing medical symptoms; 5. results from diagnostic tests pertinent to the diagnosis taken within the last six months; 6. photo documentation (front and lateral shoulder to waist) confirming breast hypertrophy taken within the last six months; 7. the surgical treatment plan described in Section II.B; 8. evidence of consideration and rule-out of comorbid etiologies of the symptoms; and 9. other pertinent clinical information that MassHealth may request. C. Clinical information must be submitted by the surgeon involved in the member 9s care. Providers must submit all information pertinent using the Automated Prior Authorization System (APAS) at www.masshealth-apas.com or by completing a MassHealth Prior Authorization Request form and attaching pertinent documentation. Select References American Society of Plastic Surgeons. Position Paper. Reduction Mammaplasty: Recommended Insurance Coverage Criteria for Third-Party Payers, 2002. Aston SJ, Beasley RW, Thorne CH, (Eds.). Grabb and Smith 9s Plastic Surgery . 5 th Edition. Lippincott-Raven Publishers: Philadelphia, PA, 1997. Berhman R, Kliegman H, Jenson H, (Eds.). Nelson Textbook of Pediatrics . 16 th Edition. Philadelphia, PA: W.B. Saunder Co., 2000. Bertin ML, Crowe J, Gordon SM. Determinants of surgical site infection after breast surgery. American Journal of Infection Control. 26(1): 61-65, 1998. Centers for Medicare and Medicaid Services. Local Medical and Regional Policies (LMRP) for Reduction Mammaplasty. Medicare Coverage Database Regional Carriers. Available at www.cms.hhs.gov . Guidelines for Medical Necessity Determination for Breast Reduction 3 Chadbourne EB, Zhang S, Gordon MJ, et al. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. Mayo Clinic Proceedings . 76(5): 503-510. 2001. Available at: www.mayo.edu/proceedings/2001/may/7605r1.pdf . Chao JD, Memmel HC, Redding JF, Egan L, Odom LC, Casas LA. Reduction mammaplasty is a functional operation, improving quality of life in symptomatic women: a prospective, single-center breast reduction outcome study. Plastic and Reconstructive Surgery . December 2002. 110(7): 1644-52. Choban P and Flancbaum L. The impact of obesity on surgical outcomes: A review. Journal of American College of Surgeons . 1997. 185: 593-603. Choban P and Heckler R. Increased incidence of nosocomial infections in obese surgical patients. American Surgeon . 1995. 61(11): 1001-1005. Dindo D, Muller M, Weber M, Clavien P. Obesity on general elective surgery. Lancet. June 2003. 361: 2032- 2035. Collins ED, et al. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plastic and Reconstructive Surgery. 2002. 109: 1556, 1559, 1563-64. FlancBaum L, et al. Surgical implications of obesity. Annual Review of Medicine . 1998. 49: 215-34. Glatt BS, Sarwer DB, O 9Hara DE, et al. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Plastic and Reconstructive Surgery. 1999. 103: 76. Hooper DM, Ricciardelli EJ, Goel VK, Aleksiev A. Biomechanical changes in the low back following reduction mammaplasty surgery. Clinical Biomechanics. Bristol, Avon. October 1997. 12(7-8): 525-527. Howrigan P. Reduction and augmentation mammoplasty. Obstetrics and Gynecology Clinics of North America , September 1994. 21(3): 539-549. Kerrigan CL, Collins ED, Striplin D, Kim HM, Wilkins E, Cunningham B, Lowery J. The health burden of breast hypertrophy. Plastic and Reconstructive Surgery. 2001. 108(6): 1591-1599. Kerrigan CL, Collins ED, Kim HM, Schnur PL, Wilkins E, Cunningham B, Lowery J. Reduction mammaplasty: defining medical necessity. Medical Decision Making . May-June 2002. 208-217. Miller AP, Zacher JB, Berggren RB, et al. Breast reduction for symptomatic macromastia: Can objective predictors for operative success be identified? Plastic and Reconstructive Surgery . 1995. 95(1): 77-83. National Institutes of Health. Clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults. The Evidence Report. National Heart, Lung and Blood Institute. NIH Publication No. 98- 4083. September 1998. Schnur PL, Hoehn JG, Ilstrup DM, Cahoy MJ and Chu CP. Reduction mammaplasty, cosmetic or reconstructive procedure? Annals of Plastic Surgery. 1991. 27: 232-237. Schnur PL, Schnur DP, et. al. Reduction mammaplasty: An outcome study. Plastic and Reconstructive Surgery . 1997. 100: 875-83. Seitchik MW. Reduction mammaplasty: Criteria for insurance coverage. Plastic and Reconstructive Surgery. 1995. 95: 1029. Guidelines for Medical Necessity Determination for Breast Reduction 4 Sood R, Mount DL, Coleman JJ 3 rd , Ranieri J, Sauter S, Mathur P, Thurston B. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. Plastic and Reconstructive Surgery . February 2003. 111(2): 688-94. Zubowski R, Zins JE, Kaplan A, Yetman RJ, Lucas AR, Papay FA, Heil D, Hutton D. Relationship of obesity and specimen weight to complications in reduction mammaplasty. Plastic and Reconstructive Surgery. 106(5): 998- 1003. These Guidelines are based on review of the medical literature and current practice in breast reduction procedures. MassHealth reserves the right to review and update the contents of these Guidelines and cited references as new clinical evidence and medical technology emerge. Policy Effective Date: April 1, 2005 Approved by: , Medical Director Revised July 1, 2005

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