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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 indications for specific surgical procedure 
        1. Breast reconstruction of the affected and the contralateral unaffected breast following a medically 
necessary mastectomy is covered. 
        2. Removal or revision of a breast implant whether placed for reconstructive or cosmetic reasons, is 
considered medically necessary when it is removed for one of the following reasons: 
            a. Mechanical complication of breast prosthesis; including rupture or failed implant, and/or implant 
extrusion. 
            b. Infection or inflammatory reaction due to a breast prosthesis; including infected breast implant, or 
rejection of breast implants. 
            c. Other complication of internal breast implant; including siliconoma, granuloma, interference with 
diagnosis of breast cancer, and/or painful capsular contracture with disfigurement. 
        3. Breast Reduction is the surgical reshaping of the breasts to reduce or lift enlarged or sagging breasts. 
Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit. 
 
        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: musculoskeletal, 
respiratory, and integumentary. Unilateral hypertrophy may result in symptoms following contralateral 
mastectomy. 
 
        Medical necessity for a breast reduction 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 or correct asymmetry following cancer surgery on one breast. 
 
            Note: either the involved breast or contralateral breast may be treated to achieve symmetry. 
            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. 
 
        Non-surgical interventions preceding breast reduction 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. 
 
        A medically reasonable and necessary breast reduction 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, neck or shoulder pain from macromastia and unrelieved by 6 months of: 
            - Conservative analgesia, 
            - Supportive measures (garment, etc.), 
            - Physical Therapy, or 
            Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent 
symptoms and/or significant restriction of activity, or 
            Intertriginous maceration or infection of the inframammary skin refractory related to dermatologic 
measures. 
            Permanent shoulder grooving with skin irritation by supporting garment (bra strap). 
 
        The amount of breast tissue to be removed must be proportional to the body surface area (BSA) per the 
Schnur18 scale below. If the individuals body surface area and weight of breast tissue removed fall above the 
22nd percentile, then the surgery is considered medically reasonable and necessary with the appropriate 
criteria. If only one breast meets the Schnur scale criteria; breast tissue may be removed from the other breast 
in order to achieve symmetry. 
 
Abdominal Lipectomy/Panniculectomy 
 
    Panniculectomy will be considered medically necessary when the pannus or panniculus hangs below the 
level of the pubis, and the medical records document that the panniculus causes chronic intertrigo (dermatitis 
occurring on opposed surfaces of the skin, skin irritation, infection or chafing that consistently recurs or 
remains refractory to appropriate medical therapy (e.g. topical antifungals, corticosteroids, antibiotics) over a 
period of 3 months.12 
    When surgery is performed to alleviate such complicating factors as inability to walk normally due to pannus 
size, chronic pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis, such surgery is 
considered reconstructive. Preoperative photographs may be required to support justification and should be 
supplied upon request.12 
    This procedure may also be medically necessary for the patient that has had a significant weight-loss 
following the treatment of morbid obesity, in addition to meeting the criteria noted above, there should be 
evidence that the individual has maintained a stable weight for at least 6 months. If the weight loss is the result 
of bariatric surgery, abdominoplasty/panniculectomy should not be performed until at least 18 months after 
bariatric surgery and only when weight has been stable for at least the most recent 6 months and infection and 
inflammation has continued for the most recent 3 months 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Cosmetic and 
Reconstructive Surgery (L39051). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.