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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 cosmetic surgery and related services, except as required for the prompt repair of accidental 
injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 
CFR Section 411.15(h). 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
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 (ADLs) 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 
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 these rules in the Local Coverage Determination (LCD) for Plastic Surgery, L37020. 
 
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.