Reduction Mammaplasty

Before November 1, 2026: Billing team must implement policy controls to require prior authorization for reduction mammaplasty (CPT 19318) claims. Update pre-authorization workflow to verify: (1) patient meets age criteria (18+ or 16+ with documented medical necessity), (2) breast tissue removal meets Schnur Sliding Scale minimums based on calculated body surface area, and (3) clinical documentation supports one of four medically necessary indications (preparatory mastectomy procedure, chronic pain with failed conservative therapy, intertrigo despite conservative treatment, kyphosis on x-ray, or ulnar paresthesia with failed conservative therapy). Providers must submit: total breast tissue to be removed (L/R specification), patient height and weight, and supporting clinical notes from referring provider (not surgeon) documenting symptom duration, evaluation for alternative causes, and three months of conservative therapy attempts. Educate providers that liposuction-only breast reduction will be denied as investigational; liposuction combined with reduction mammaplasty will be denied as not medically necessary. Update encounter forms and EMR templates to capture required documentation elements before surgery scheduling. Configure billing system to reject claims lacking Schnur Scale compliance documentation. Flag all gynecomastia cases for denial per policy Section III.