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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 reduction mammoplasty is covered by Medicare when it is performed: 1. To reduce the size of the hypertrophic breast(s) and reduce or alleviate symptoms caused by the breast hypertrophy, or 2. To reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after breast cancer surgery. You can find this rule in Local Coverage Determination (LCD): Plastic Surgery (L35163) - Effective October 1, 2019. The rules say that 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. You can find this rule in Local Coverage Determination (LCD): Plastic Surgery (L35163) - Effective October 1, 2019. The rules say that for Medicare purposes, a reasonable and necessary reduction mammoplasty may be indicated in the presence of significantly enlarged breasts and the presence of at least two of the following signs and/or symptoms when the breast hypertrophy and the symptoms and signs have been present for at least six months and have not responded to a reasonable non-surgical care program: -Upper back, shoulder and /or neck pain that appears to be directly correlated to the macromastia. -Headache (cephalgia) when same can be directly attributed to the excessive breast weight and its effect on the neck and/or shoulders and other reasonable causes of a headache have been addressed/ruled out. -Significant thoracic kyphosis which is felt to be directly correlated to the breast hypertrophy. -Chronic breast pain due to the excessive weight of the breasts. -Intertriginous maceration or infection of the inframammary skin refractory to usual dermatologic measures. -Shoulder grooving from supporting garment (bra strap). -Upper extremity paresthesia due to brachial plexus compressions syndrome secondary to the weight of the breasts being transferred to the shoulder strap area. You can find this rule in Local Coverage Determination (LCD): Plastic Surgery (L35163) - Effective October 1, 2019.
The rules say that physicians should document the severity of the symptoms of breast hypertrophy and impact on health related quality of life as measured by an accepted breast specific questionnaire. The beneficiary's medical record must contain the following information and be made available to any authorized Medicare auditor upon request: -Height and weight -Clinical evaluation of the signs and/or symptoms ascribed to the macromastia, therapies prior to reduction mammoplasty and the responses to these therapies. -The operative report with documentation of the weight of tissue removed from each breast, obtained in the operating room. -The pathology report of the tissue removed from each breast. You can find this rule in Local Coverage Article: Billing and Coding: Plastic Surgery (A57221) - Effective October 1, 2019. The rules say that the reasons for denial for reduction mammaplasty include: 1. Surgery is deemed or later determined to be cosmetic in nature. Breast surgery for uncomplicated macromastia, pendulous breasts, or to correct otherwise uncomplicated nipple inversions will be considered cosmetic and not reasonable and necessary. 2. Failure to clearly document persistent signs and symptoms despite a reasonable trial of conservative therapy for a reasonable length of time. 3. Services submitted without a listed diagnosis (ICD-10-CM) code supporting medical necessity. You can find this rule in Local Coverage Article: Billing and Coding: Plastic Surgery (A57221) - Effective October 1, 2019.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.