JOHNS HOPKINS HEALTHCARE

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1 Page 1 of 6 ACTION: New Policy: Combining CMS02.03 and CMS07.01 Revising Policy Number Superseding Policy Number: Archiving Policy Number Retiring Policy Number Johns Hopkins HealthCare provides a full spectrum of health care products and services for Employer Health Programs, Priority Partners, and US Family Health Plan. Each line of business possesses its own unique contract and guidelines which, for benefit and payment purposes, should be consulted to know what benefits are available for reimbursement. Specific contract benefits, guidelines or policies supersede the information outlined in this policy. POLICY: For US Family Health Plan see TRICARE Policy Manual M, February 1, 2008, Cosmetic, Reconstructive and Plastic Surgery General Guidelines: Chapter 4, Section 2.1 and Reduction Mammaplasty for Macromastia: Chapter 4, Section 5.4. I. Reduction Mammoplasty for Females Johns Hopkins HealthCare (JHHC) considers Reduction Mammoplasty for Females medically necessary when ALL of the following criteria are met: A. Age and sexual maturity (BOTH) 1. Member is at least 18 years of age 2. Member has achieved sexual maturity as demonstrated by: a. Tanner Stage V breast development b. 24 months post menarche B. History and physical examination include at least TWO of the following established, treated, and documented by a physician other than the surgeon: 1. Permanent shoulder grooving from bra straps bilaterally 2. Chronic, unremitting intertrigo, unresponsive to standard preventive and therapeutic measures for a period of at least six months 3. Back, shoulder, neck or breast pain unresponsive to at least three months of conservative therapeutic measures including at least TWO of the following: a. Supportive devices (e.g., proper bra support, wide bra straps) b. Analgesic/non-steroidal anti-inflammatory drug (NSAIDs) intervention c. Physical therapy/exercises/posturing maneuvers 4. Paresthesias of the hands or arms

2 Page 2 of 6 C. Estimated excess breast tissue per breast to be removed (ONE): g to 238 g and BSA 1.35 to g to 284 g and BSA 1.46 to g to 349 g and BSA 1.56 to > 350 g Simplified formula for calculation of body surface area (Mosteller Formula): BSA (in m 2 ) =([Height (cm) x Weight (kg)]/ 3600) (1/2) D. Women 40 years of age or older are required to have a mammogram that was negative for cancer performed within the year prior to the date of the planned reduction. E. JHHC considers mastopexy cosmetic unless performed as a component of breast reconstruction following mastectomy for breast cancer. F. JHHC considers repeat breast reduction surgery not medically necessary. II. Reduction Mammoplasty for Males Johns Hopkins HealthCare (JHHC) considers Reduction Mammoplasty for Males with unilateral or bilateral gynecomastia medically necessary when ALL of the following criteria are met: A. Age and sexual maturity (BOTH) 1. Member is at least 18 years of age 2. Tanner Stage V development documented for a minimum of one year B. Pain or tenderness of glandular breast tissue (not associated adipose tissue) C. Documentation includes photos and physical exam evidence of Grade II, III or IV gynecomastia D. Contributory medical conditions have either been excluded or identified and adequately treated for > 6 months E. Comprehensive medication review (BOTH) 1. THC use excluded by urine drug screen 2. Prescribed medications reviewed and (ONE) a. All prescribed medications deemed non-contributory; or b. Contributory medication(s) discontinued; or c. Prescribing physician certifies that there is no acceptable therapeutic alternative to a contributory medication F. Requests for reduction mammoplasty can be considered for males under age 18, who have achieved sexual maturity (Tanner Stage V) for > 1 year on a case by case basis. BACKGROUND: Hypertrophy of the breast (macromastia and gigantomastia) is a rare but disabling condition of excessive growth of breast tissue. Breast weight in excess of approximately 3% of total body weight is generally accepted as the indication for hypertrophy of the breast. Some clinicians further distinguish between macromastia as excessive breast tissue less than 2.5 kilograms and

3 Page 3 of 6 gigantomastia where excessive breast tissue is greater than 2.5 kilograms. A common complaint among women suffering from macromastia is pain in the upper and lower back, head, neck, shoulders and breasts. There may be complaint of numbness and tingling of the fingers. There may also be complaints of disability and loss of function. Often the medical histories of these women describe episodes of chronic intertriginous rash of the inframammary fold and physical evidence of shoulder grooving from brassiere straps is documented. Conservative medical management (weight loss, adequate bra support, nonsteroidal antiinflammatory drugs and/or physical therapy) is usually recommended to reduce symptoms of pain, improve posture, and assist in skin healing. Failure of the patient to respond to medical management may result in a recommendation for surgical intervention. Breast reduction surgery (reduction mammoplasty or mammaplasty) may be performed related to the hypothesis that reducing breast weight will relieve pain, will decrease disability, and will increase function. There are no definitive controlled studies supporting the effectiveness of surgical removal of excessive breast tissue. Most medical literature discusses surgical outcomes in terms of relief from pre-operative symptoms of pain and an improved quality of life. Gynecomastia is a clinical condition in which males exhibit benign enlargement of breast tissue which may be related to an imbalance of the hormones estrogen and testosterone. Gynecomastia may be transient. It may be unilateral or bilateral. Males may complain of breast swelling, pain, tenderness, and/or nipple discharge. Gynecomastia may also manifest as an abnormal clinical condition associated with diseases such as hypogonadism, tumors, hyperthyroidism, kidney failure, liver failure and cirrhosis, and malnutrition. Medications such as the following may also influence the hormonal balance resulting in male breast enlargement: anti-androgens, anabolic steroids, AIDS drugs, anti-anxiety drugs, tricyclic antidepressants, antibiotics, cancer treatments, cardiac medications, and drugs used to treat gastrointestinal ulcers. Use of alcohol, amphetamines, marijuana, heroin, and methadone may also influence hormonal balance. The aging process can induce gynecomastia in males. Most cases of gynecomastia resolve over time without treatment. Treating the underlying medical condition or implementing changes in the male s medications may resolve other cases. Failure to respond to conservative medical management may result in the recommendation for surgery. Surgical intervention may be in the form of liposuction or mastectomy. CODING INFORMATION: CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

4 Page 4 of 6 Note: The following CPT/HCPCS codes are included below for informational purposes. Inclusion or exclusion of a CPT/HCPCS code(s) below does not signify or imply member coverage or provider reimbursement. The member's specific benefit plan determines coverage and referral requirements. All inpatient admissions require preauthorization. PRE-AUTHORIZATION REQUIRED Compliance with the provision in this policy may be monitored and addressed through post-payment data analysis and/or medical review audits Employer Health Programs (EHP) **See Specific Summary Plan Description (SPD) Priority Partners (PPMCO) refer to COMAR guidelines and PPMCO SPD then apply policy criteria US Family Health Plan (USFHP), TRICARE Medical Policy supersedes JHHC Medical Policy. If there is no Policy in TRICARE, apply the Medical Policy Criteria CPT CODES DESCRIPTION Mastectomy for Gynecomastia Mastopexy Reduction mammaplasty Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction. REFERENCES: PRIMARY SCIENTIFIC CLINICAL RESEARCH REFERENCE ARTICLES 1. Schnur PL, Hoehn JG, Ilstrup DM, Cahoy MJ, Chu CP, Reduction Mammaplasty; Cosmetic or Reconstructive procedure? Annals of Plastic Surgery, 1991 September; 27 (3): Retrieved from: 2. Schnur PL, Schnur DP, Petty PM, Hanson TJ, Weaver AL, Reduction Mammaplasty: An Outcome Study. Plastic and Reconstructive Surgery, 1997, September, Vol 100, No 4; Retrieved from: 3. American Society for Plastic Surgery (2014), What is Breast Reduction? Retrieved from: 4. American Society of Plastic Surgeons. Evidence-based clinical practice guideline:

5 Page 5 of 6 reduction mammaplasty. Arlington Heights (IL): American Society of Plastic Surgeons; 2011 May. Retrieved from: 5. Kerrigan CL, Collins ED, Kim HM, Schnur PL, Wilkins E, Cunningham B, Lowery J, Reduction Mammaplasty: Defining Medical Necessity. Medical Decision Making, 2002, May 1, Retrieved from: 6. Banikarim C, De Silva N K, Overview of Breast Disorders in children and adolescents, retrieved from: 7. Braunstein GD, (last updated 2014, April 25). Epidemiology and Pathogenesis of Gynecomastia]. Retrieved from: 8. Braunstein GD (last updated 2013, June 11). Management of Gynecomastia. Retrieved from: 9. Gruntmanis U, Braunstein GD, (2001, May). Treatment of Gynecomastia [Abstract]. Current Opinion in Investigational Drugs, Volume 2(5), Retrieved from: Braunstein GD, (1999, June). Aromatase and Gynecomastia [Abstract]. Endocrine- Related Cancer, Volume 6(2), Retrieved from: CLINICAL TECHNOLOGY RESEARCH AND CONSULTING REFERENCES 11. Hayes, Inc., Medical Technology Directory, (Published: 2008, December 18: archived 2014, January 18), Reduction Mammoplasty. Retrieved from: Hayes, Inc, Health Technology Brief, (Published 2010, July 12; archived 2013, August 6), Mastectomy for Gynecomastia. Retrieved from: HEALTH PLAN REFERENCES 13. CIGNA Medical Coverage Policy, Reduction Mammoplasty, Policy Number: 0152, Effective Date: 2013, August 15. Retrieved from: overagepositioncriteria_reduction_mammoplasty_for_macromastia.pdf 14. CIGNA Medical Coverage Policy, Surgical Treatment of Gynecomastia, Policy Number: 0195, Effective Date: 2013, October 15. Retrieved from:

6 Page 6 of 6 overagepositioncriteria_surgical_treatment_of_gynecomastia.pdf 15. Aetna Clinical Policy Bulletin: Breast Reduction Surgery and Gynecomastia Surgery, Policy Number: 0017, Last Review: 2013, December 4. Retrieved from: REGULATORY GOVERNMENT REFERENCES 16. TRICARE Policy Manual M, Reduction Mammaplasty for Macromastia, Chapter 4, Section 5.4. Retrieved from: ype=asof&filename=c4s5_4.pdf&highlight=xml%3dhttp%3a%2f%2fmanuals.tricar e.osd.mil%2fpdfhighlighter.aspx%3fdocid%3d33035%26index%3dd%253a%255cind ex%255ctp08%26hitcount%3d8%26hits%3d12%2b31%2b69%2b107%2b11f%2b17b %2b192%2b19e%2b 17. TRICARE Policy Manual M, Gynecomastia, Chapter 4, Section 5.7. Retrieved from: ype=asof&filename=c4s5_7.pdf&highlight=xml%3dhttp%3a%2f%2fmanuals.tricar e.osd.mil%2fpdfhighlighter.aspx%3fdocid%3d33038%26index%3dd%253a%255cind ex%255ctp08%26hitcount%3d7%26hits%3d11%2b2b%2b39%2b57%2b70%2ba4%2 be3%2b 18. TRICARE Policy Manual M, Cosmetic, Reconstructive, and Plastic Surgery General Guidelines, Chapter 4, Section 2.1. Retrieved from: ype=asof&filename=c4s2_1.pdf&highlight=xml%3dhttp%3a%2f%2fmanuals.tricar e.osd.mil%2fpdfhighlighter.aspx%3fdocid%3d33028%26index%3dd%253a%255cind ex%255ctp08%26hitcount%3d1%26hits%3d22c%2b