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Decision: unknown

 
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 cosmetic surgery is performed to reshape normal structures of the body to improve the 
patient's appearance and self-esteem. Surgery to correct congenital defects, developmental abnormalities, 
trauma, infections, tumors, or disease may be covered when the surgery is considered reconstructive in nature. 
Cosmetic surgery performed purely for the purpose of enhancing one's appearance is not eligible for coverage. 
Cosmetic surgery performed to treat psychiatric or emotional problems is not covered. You can find this rule in 
the Local Coverage Determination (LCD) - Plastic Surgery (L35163) - Effective October 1, 2019. 
 
The rules say that 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; 
 
You can find this rule in the Local Coverage Determination (LCD) - Plastic Surgery (L35163) - Effective 
October 1, 2019. 
 
The rules say that reduction mammaplasty 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 the 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: 
 
1. Determining the macromastia is not due to an active endocrine or metabolic process 
2. 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. 
3. 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 the 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: 
 
1. Upper back, shoulder and /or neck pain that appears to be directly correlated to the macromastia 
2. 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 
3. Significant thoracic kyphosis which is felt to be directly correlated to the breast hypertrophy. 
4. Chronic breast pain due to the excessive weight of the breasts. 
5. Intertriginous maceration or infection of the inframammary skin refractory to usual dermatologic measures. 
6. Shoulder grooving from supporting garment (bra strap). 
7. 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 the Local Coverage Determination (LCD) - Plastic Surgery (L35163) - 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.