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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say that macromastia (breast hypertrophy) is disproportionate volume and weight of breast tissue relative to the general body habitus. Breast hypertrophy may adversely affect other body systems (e.g., musculoskeletal, respiratory, integumentary). Unilateral hypertrophy may result in symptoms following contralateral mastectomy. Reduction mammoplasty is performed: -To reduce the size of the breasts and help ameliorate symptoms caused by hypertrophy. -To reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery. You can find this rule in Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L33428) - Effective October 24, 2019. The rules say that medical necessity for reduction mammoplasty is limited to circumstances in which: -There are signs and/or symptoms resulting from the enlarged breasts (macromastia) that have not responded adequately to non-surgical interventions. -To improve symmetry following cancer surgery on one breast. -The signs and/or symptoms have been present for at least six months. -Medical treatment and/or physical interventions have not adequately alleviated symptoms. For Medicare purposes, a reasonable and necessary reduction mammoplasty could be indicated in the presence of significantly enlarged breasts and the presence of at least one of the following signs and/or symptoms: -Back pain from macromastia, unrelieved by: 1. Conservative analgesia 2. Supportive measures (garment, etc.) 3. Physical therapy -Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity. -Intertriginous maceration or infection of the inframammary skin refractory to dermatologic measures. -Shoulder grooving with skin irritation by supporting garment (bra strap). You can find this rule in Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L33428) - Effective October 24, 2019. The rules say that considerable attention has been given to the amount of breast tissue removed in differentiating between cosmetic and medically necessary reduction mammoplasty. Arbitrary minimum weight breast tissue removed criteria do not consistently reflect the consequences of mammary hypertrophy in individuals with a unique body habitus. There are wide variations in the range of height, weight and associated breast size that cause symptoms. The amount of tissue that must be removed to relieve symptoms will vary and depend upon these variations. The following are guidelines (not rules) that address the patient's weight and the amount of breast tissue removed: -95-119 lbs. 300 grams excised per breast. -110-130 lbs. 400 grams excised per breast.
-130+ lbs. 500 grams excised per breast. You can find this rule in Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L33428) - Effective October 24, 2019.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.