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AetnaAll Plans · Coverage · Surgery · Plastic Surgery, General SurgeryMedium impact

Breast Reduction Surgery and Gynecomastia Surgery (CPB 0017, reviewed 2026-03-12)

Effective date
Not stated in the notice
Identified
Aug 14, 2026

Summary

Aetna considers reduction mammaplasty (CPT 19318) medically necessary for non-cosmetic indications in women age 18 or older, or once growth is complete with breast size stable for one year. For macromastia, the criteria require persistent symptoms in at least two listed body areas that are attributed to macromastia and affect daily activities for at least 1 year, documented severe breast hypertrophy in high-quality photographs, and symptoms that persist despite at least a 3-month trial of listed therapeutic measures. Gigantomastia of pregnancy is medically necessary when a listed complication is present and delivery is not imminent. Breast reduction, surgical mastectomy, or liposuction for gynecomastia is considered cosmetic, and several listed techniques are considered experimental, investigational, or unproven.

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What to do

Action · 7 steps
01Billing team: CPT 19318 is covered only when the selection criteria are met.
02Documentation submitted with the request must include the member's height and weight, a description of the size and configuration of the breast(s) contributing to symptoms, and the anticipated amount of breast tissue to be removed from each breast.
03Women 50 years of age or older need a negative mammogram performed within the two years before the planned procedure.
04The surgeon's preoperative evaluation must indicate that reduction mammaplasty is expected to provide meaningful improvement and that the tissue to be removed from at least one breast meets the minimum resection weight for the member's body surface area in Table 1 of the Appendix.
05Breast reduction is considered medically necessary regardless of body surface area when more than 1 kg of breast tissue is to be removed per breast and the symptomatic criteria are met.
06Chronic intertrigo, eczema, dermatitis, or ulceration in the infra-mammary fold is not considered medically necessary on its own, and must be unresponsive to dermatological treatment and conservative measures for 6 months or longer and also satisfy the symptomatic criteria.
07Breast asymmetry surgery follows the criteria in CPB 0185.

Codes mentioned

19318158771930019303N62N64.89I96G56.00G56.93L98.491L98.494

Original notice

Breast Reduction Surgery and Gynecomastia Surgery (CPB 0017, reviewed 2026-03-12)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesPlastic SurgeryGeneral SurgeryCode 19318Code 15877Code 19300Code 19303Code N62Code N64.89Code I96Code G56.00Code G56.93Code L98.491Code L98.494

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