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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 Item/Service Description 
 
During recent years, there has been a considerable change in the treatment of diseases of the breast such as 
fibrocystic disease and cancer. While extirpation of the disease remains of primary importance, the quality of 
life following initial treatment is increasingly recognized as of great concern. The increased use of breast 
reconstruction procedures is due to several factors: 
 
    A change in epidemiology of breast cancer, including an apparent increase in incidence; 
    Improved surgical skills and techniques; 
    The continuing development of better prostheses; and 
    Increasing awareness by physicians of the importance of postsurgical psychological adjustment. 
 
Indications and Limitations of Coverage 
 
Reconstruction of the affected and the contralateral unaffected breast following a medically necessary 
mastectomy is considered a relatively safe and effective noncosmetic procedure. Accordingly, program 
payment may be made for breast reconstruction surgery following removal of a breast for any medical reason. 
Program payment may not be made for breast reconstruction for cosmetic reasons. (Cosmetic surgery is 
excluded from coverage under l862(a)(l0) of the Act.) You can find this information in Medicare's National 
Coverage Determination (NCD): Breast Reconstruction Following Mastectomy (140.2). 
 
The rules say 1. Reduction Mammoplasty 
Macromastia (also called breast hypertrophy) is an increase in the volume and weight of breast tissue relative to 
the general body habitus. Macromastia may adversely affect other body systems: such as musculoskeletal, 
respiratory, and integument (skin). These symptoms include but are not necessarily limited to: 
 
    1. Muscle strain such as backache, neck pain, shoulder pain and less often upper extremity peripheral 
neuropathy and/or headache; 
    2. Problems associated with excess breast weight and brassiere support such as clavicular bra strap grooves; 
    3. Hygiene problems such as intertrigo, exacerbation of acne in the folds underneath the breast and/or local 
hidradenitis supprativa refractory to usual medical care; 
    4. Clearly demonstrated interference with normal activities of daily living as noted as noted by a breast 
specific questionnaire for ADLs;  
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. 
 
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 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 
 
The MAC understands that conservative measures are often not effective or sustained however given the risks 
of surgery these measures should be attempted for a reasonable period of time as some patients will respond 
and be able to avoid surgery and the inherent surgical risks. Complications of reduction mammaplasty surgery 
include but are not limited to: 
 
    Infection 
    Delayed wound healing 
    Wound dehiscence 
    Hematoma and/or seroma 
    Skin or nipple-areola necrosis 
    Fat necrosis 
    Cosmetic deformity 
    Unfavorable scarring 
    Alteration of nipple sensation 
    Thromboembolic complications (blood clots) 
    Inability to breast feed 
    Need for surgical revision 
    Need for physical therapy 
    Potential for anesthesia related complications  
Considerable attention has been given to the amount of breast tissue removed in differentiating between 
cosmetic and medically necessary reduction mammoplasty. Evidence indicates that patients experience similar 
preoperative breast hypertrophy related symptoms and similar postoperative symptom relief after reduction 
mammaplasty regardless of resection volume 
 
In a prospective trial of 188 patients undergoing reduction mammaplasty for macromastia related symptoms the 
degree of relief was not correlated with the amount of breast volume removed. The surgeon must document in 
the clinical records the amount of tissue reduction anticipated and the rationale on how that amount was 
determined. 
 
Medicare coverage of reduction mammoplasty is limited to those circumstances where the medical record 
supports medical necessity and reasonableness criteria including: 
 
    The signs and/or symptoms have been present for at least six months 
    Medical treatment and/or physical interventions have not adequately alleviated symptoms 
    The patient has been informed of the risks of complications 
    The notes indicate the proposed amount of tissue to be removed and the rationale supporting that 
determination 
 
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. You can find this information in Medicare's Local Coverage Determination (LCD): Plastic Surgery 
(L37020). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.