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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 Code of Federal Regulations (CFR) Section 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. 
 
Medicare 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. 
 
NOTE: For coverage indications for contralateral reconstruction of an unaffected breast following a medically 
necessary mastectomy, refer to the CMS Internet-Only Manual,  Pub. 100-03, Medicare National Coverage 
Determinations Manual, Chapter 1, Part 2, ?140.2. 
 
Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit. Cosmetic signs 
and/or symptoms would include ptosis, poorly fitting clothing and beneficiary perception of unacceptable 
appearance. 
 
Non-surgical interventions preceding reduction mammoplasty should include as appropriate, but are not limited 
to, the following: 
 
Determining the macromastia is not due to an active endocrine or metabolic process. 
 
    Determining the symptoms are refractory to appropriately fitted supporting garments, or following unilateral 
mastectomy, persistent with an appropriately fitted prosthesis or reconstruction therapy at the site of the absent 
breast. 
    Determining that dermatologic signs and/or symptoms are refractory to, or recurrent following, a completed 
course of medical management. 
 
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: 
 
        Conservative analgesia 
        Supportive measures (garment, etc.) 
        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). 
 
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: 
 
Table I 
 
    95-119 lbs. 300 grams excised per breast. 
    110-130 lbs. 400 grams excised per breast. 
    130+ lbs. 500 grams excised per breast. 
 
Medicare coverage of reduction mammoplasty is limited to those circumstances where the medical record 
supports the following: 
 
    The signs and/or symptoms have been present for at least six months. 
    Medical treatment and/or physical interventions have not adequately alleviated symptoms. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Cosmetic and 
Reconstructive Surgery (L33428). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.