CommercialCoverageMedium impact
Reduction Mammaplasty (Mammoplasty) 7.01.39
Excellus BlueCross BlueShield·NY · Plastic Surgery, General Surgery, OB-GYN·Cosmetic / Reconstructive Surgery
Effective date
Jul 17, 2025
We identified it
Jun 20, 2026
Summary
Excellus BlueCross BlueShield updated their reduction mammaplasty policy effective July 17, 2025, establishing specific medical necessity criteria including persistent symptoms for at least one year and minimum tissue removal requirements based on body surface area or 500g per breast. The policy clarifies that procedures for breast symmetry after mastectomy are medically appropriate under Federal and NY State law.
Action Required
By July 17, 2025: Billing team must update prior authorization processes for reduction mammaplasty procedures to verify all medical necessity criteria are met including: 1) Document persistent symptoms for at least one year affecting daily activities, 2) Verify minimum tissue removal requirements using Schnur Sliding Scale (22nd percentile) or 500g per breast minimum, 3) Confirm patients under 18 have completed breast maturation with stable bra size for one year. Update encounter forms to prompt providers for required documentation including height, weight, planned tissue removal in grams, and symptom duration. Claims may be denied without proper documentation.