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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 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 (e.g., 
musculoskeletal, respiratory, integumentary). At times, unilateral hypertrophy may result in symptoms 
following contralateral mastectomy. Considerable attention has been given to the amount of breast tissue 
removed in differentiating between cosmetic and medically reasonable and necessary reduction mammoplasty. 
Arbitrary minimum weight breast tissue removed criteria do not consistently reflect the consequences of 
mammary hypertrophy in individuals with a unique body habitus. There are wide variations in the range of 
height, weight and associated breast size that cause symptoms. The amount of tissue that must be removed to 
relieve symptoms will vary and depend upon these variations. 
 
The Schnur sliding scale is an evaluation method for physicians to use on individuals considering breast 
reduction surgery. If the individual's 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.
 
The 
scale abbreviated below allows a rough estimate of the minimal amount of soft tissue to be removed to justify 
surgery to alleviate symptoms based on body surface area; breast tissue may be removed from the other breast 
in order to achieve symmetry. 
 
Gestational or pregnancy-included gigantomastia occurs during pregnancy. This subtype is thought to be 
triggered by pregnancy hormones, usually during the first trimester. It occurs in just 1 out of every 100,000 
pregnancies. Gigantomastia may be defined as the excessive overgrowth of breast tissue per breast unilaterally 
or bilaterally, however, there is no universally accepted definition for the amount of growth. Gigantomastia has 
been associated with pregnancy, puberty, certain medications and certain autoimmune conditions. Extreme 
breast enlargement and excess weight of the breasts can result in physical complications including 
overstretching of the skin, skin rashes under the breasts, ulcers on the skin, neck, shoulder and back pain, 
headaches, mastalgia, breast asymmetry, temporary or permanent nerve damage, psychological, emotional and 
social problems. Hormonal treatment or a combination of treatments may be performed to reduce the size of 
the breasts and help ameliorate symptoms caused by hypertrophy of the breast(s). Literature review has shown 
that puberty and pregnancy-included gigantomastia may reoccur after breast reduction surgery and that 
mastectomy is a more final treatment for gigantomastia. A reduction mammoplasty or mastectomy with or 
without reconstruction is considered medically reasonable and necessary. 
 
You can find these rules in the Local Coverage Determination (LCD) for Cosmetic and Reconstructive 
Surgery, L35090.  
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.