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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 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. 
 
You can find this information in the 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.