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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 state that reduction mammaplasty is the surgical removal of a substantial portion of the breast, 
including the skin and underlying glandular tissue, until a clinically normal size is obtained. Breasts are pair 
organs, and breast hypertrophy generally affects both sides, therefore, bilateral surgery is usually performed. 
 
Reduction mammaplasty is performed to reduce the size of the breasts and help ameliorate symptoms caused 
by the hypertrophy and to reduce the size of a normal breast to bring it into symmetry with a breast 
reconstructed after cancer surgery. 
 
Indications: 
Reduction mammaplasty is considered medically necessary: 
 
    When the patient has significant symptoms that have interfered with normal daily activities, despite 
conservative management, for at least 6 months, including at least one of the following criteria: 
 
    History of back and/or shoulder pain which adversely affects activities of daily living (ADLs) unrelieved by, 
e.g.: 
        conservative analgesia (e.g., such as NSAID, compresses, massage, etc.) 
        supportive measures (e.g., such as garments, back brace, etc.), 
        physical therapy 
        correction of obesity 
    History of significant arthritic changes in the cervical or upper thoracic spine, optimally managed with 
persistent symptoms and/or significant restriction of activity, e.g.: 
        Signs and symptoms of ulnar paresthesias 
        Cervicalgia 
        Torticollis 
        Acquired kyphosis 
 
Signs and symptoms of: 
 
    intertrigonous maceration or infection of the inframammary skin (e.g., hyperpigmentation, bleeding, chronic 
moisture, and evidence of skin breakdown), refractory to dermatologic measures, or 
    shoulder grooving with skin irritation (e.g., areas of excoriation and breakdown) by appropriate supporting 
garment  
AND 
 
Considerable attention has been given to the amount of breast tissue removed in differentiating between 
cosmetic and medically necessary reduction mammoplasty. To be considered a non-cosmetic procedure it is 
expected that at least a minimal amount of breast tissue will be removed. Yet, 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 in order to relieve symptoms will vary and 
depend upon these variations. 
 
The following are guidelines (not rules) that address the patient's body surface area (BSA) and the amount of 
breast tissue removed 
BSA 1.35-1.45 199-238 
BSA 1.46-1.55 239-284 
BSA 1.56-1.69 285-349 
Equal to or greater than 350g 
 
You can find this information in the Local Coverage Determination (LCD) Reduction Mammaplasty L35001. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.