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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 an increase in the 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. - After full breast evaluation including recent mammogram (over the age 35). - With histologic pathology performed on all breast tissue resected. Medicare medical necessity for reduction mammoplasty is limited to circumstances in which: - There are signs or symptoms resulting from the enlarged breasts (macromastia) that have not responded adequately to non-surgical interventions. - To improve or correct asymmetry following cancer surgery on one breast. Note: either the involved breast or contralateral breast may be treated to achieve symmetry. 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, pharmaceutical 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 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 or symptoms: - Back pain from macromastia, unrelieved by: o Conservative analgesia. o Supportive measures (custom garment, etc.). o Physical therapy. - Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms or significant restriction of activity. - Intertriginous maceration, discoloration, chronic or recurrent infection of the inframammary skin refractory to dermatologic treatment measures. - Shoulder grooving to a depth greater than 1 cm with skin irritation or darkening. - Graphic documentation of ptosis with nipple-areolar complex 8 cm below the inframammary crease. - Surgeon's Estimate of breast size/weight/volume exceeds 1000 grams with the need for at least 500 gram reduction per breast to relieve symptoms. 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 Schnur scale (abbreviated below) allows a rough estimate of the minimal amount of soft tissue to be removed to justify surgery to alleviate symptoms based on body surface area; breast tissue may be removed from the other breast in order to achieve symmetry.
You can find this rule in the Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L35090) effective November 7, 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.