Local Coverage Determination (LCD)

Reduction Mammaplasty


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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
Original ICD-9 LCD ID
Not Applicable
LCD Title
Reduction Mammaplasty
Proposed LCD in Comment Period
Source Proposed LCD
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 02/01/2024
Revision Ending Date
Retirement Date
Notice Period Start Date
Notice Period End Date
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Issue Description

The LCD defines medical necessity guidelines for reduction mammaplasty.

Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Section 1862(a)(7) excludes routine physical examinations, unless otherwise covered by statute.

CMS Publications:

CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Part 2:

    Section 140.2 Breast Reconstruction Following Mastectomy

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity


Reduction mammaplasty is the surgical removal of a substantial portion of the breast, including the skin and underlying glandular tissue, until a clinically normal size is obtained. Breasts are pair organs, and breast hypertrophy generally affects both sides, therefore, bilateral surgery is usually performed.

Reduction mammaplasty is performed to reduce the size of the breasts and help ameliorate symptoms caused by the hypertrophy and to reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery.

Reduction mammaplasty is considered medically necessary:

  1. When the patient has significant symptoms that have interfered with normal daily activities, despite conservative management, for at least 6 months, including at least one of the following criteria:
  • History of back and/or shoulder pain which adversely affects activities of daily living (ADLs) unrelieved by, e.g.:
    • conservative analgesia (e.g., such as NSAID, compresses, massage, etc.)
    • supportive measures (e.g., such as garments, back brace, etc.),
    • physical therapy
    • correction of obesity
  • History of significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity, e.g.:
    • Signs and symptoms of ulnar paresthesias
    • Cervicalgia
    • Torticollis
    • Acquired kyphosis

Signs and symptoms of:

  • intertriginous maceration or infection of the inframammary skin (e.g., hyperpigmentation, bleeding, chronic moisture, and evidence of skin breakdown), refractory to dermatologic measures, or
  • shoulder grooving with skin irritation (e.g., areas of excoriation and breakdown) by appropriate supporting garment



Considerable attention has been given to the amount of breast tissue removed in differentiating between cosmetic and medically necessary reduction mammoplasty. To be considered a non-cosmetic procedure it is expected that at least a minimal amount of breast tissue will be removed. Yet, 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 in order to relieve symptoms will vary and depend upon these variations.

The following are guidelines (not rules) that address the patient's body surface area (BSA) and the amount of breast tissue removed
BSA 1.35-1.45 199-238
BSA 1.46-1.55 239-284
BSA 1.56-1.69 285-349
Equal to or greater than 350g

Limitations of Coverage:

1. Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit.
2. Indications of Coverage must be met.

Note: Reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is considered a non-cosmetic procedure. National coverage provides for payment of breast reconstruction surgery following removal of a breast for any medical reason.

Summary of Evidence


Analysis of Evidence (Rationale for Determination)


Proposed Process Information

Synopsis of Changes
Changes Fields Changed
Associated Information
Sources of Information
Open Meetings
Meeting Date Meeting States Meeting Information
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
MAC Meeting Information URLs
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

Revenue Codes

Code Description


Group 1

Group 1 Paragraph


Group 1 Codes



ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:


Group 1 Codes:



ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:


Group 1 Codes:



Additional ICD-10 Information

General Information

Associated Information
Sources of Information

Wagner DS, Alfonso DR. The influence of obesity and volume resection on success in reduction mammaplasty: an outcomes study. Plast Reconstr Surg. 2005 Apr;115(4):1034-8

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
02/01/2024 R3

Updated only to correct the spelling of intertriginous. 

  • Typographical Error
11/07/2019 R2

Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A56837. There has been no change in coverage with this LCD revision.

  • Revisions Due To Code Removal
10/01/2015 R1 Added the following ICD-10-CM diagnosis codes to the ICD-10 Codes that Support Medical Necessity section, effective for services rendered on or after 10/01/2015: D05.90, D05.91, D05.92, N65.0, and N65.1.
  • Request for Coverage by a Practitioner (Part B)

Associated Documents

Related Local Coverage Documents
A56837 - Billing and Coding: Reduction Mammaplasty
Related National Coverage Documents
Public Versions
Updated On Effective Dates Status
02/07/2024 02/01/2024 - N/A Currently in Effect You are here
11/01/2019 11/07/2019 - 01/31/2024 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.


  • Breast Reduction
  • Breast Reconstruction
  • Cosmetic Surgery
  • Breast

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