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Breast Reduction Surgery and Gynecomastia Surgery (CPB 0017, reviewed 2026-10-26)
Effective date
Not stated in the notice
Identified
Nov 2, 2026
Summary
Aetna's Breast Reduction Surgery and Gynecomastia Surgery policy (CPB 0017) was reviewed on 2026-10-26, and the source does not state what changed or give a new effective date. It sets the criteria for breast reduction (CPT 19318) to be covered for symptomatic macromastia, including documented symptoms, a 3-month trial of conservative care, a resection weight that meets the Schnur body surface area table or more than 1 kg per breast, and a negative mammogram for women 50 or older, and it treats gynecomastia surgery and liposuction-only reduction as cosmetic or experimental.
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What to do
Action · 5 steps
01No effective date or change date is stated in the source.
02The next scheduled review date in the source is 01/14/2027, which is a review date and not a deadline.
03Billing team: before scheduling and billing CPT 19318 for Aetna members, confirm the chart holds the documentation the policy requires and send it with the request: height and weight, a description of the breast size and configuration, the anticipated tissue removal from each breast, the symptom history with the 3-month conservative treatment record, a negative mammogram within the two years before surgery for women 50 or older, and the surgeon's preoperative assessment that the resection meets the Schnur minimum for the member's body surface area.
04Providers and front desk staff: gynecomastia surgery, suction-assisted lipectomy, mastectomy for gynecomastia, and liposuction-only reduction are listed as cosmetic or experimental, so do not bill them under 19318 and tell members these uses are not covered.
05Orthopedic or spine surgeon evaluation of spinal pain is one of the required conservative steps, so ortho practices should be ready to send those notes.
Codes mentioned
193181587719300193037740277417G56.00G56.93I96L98.491L98.494N62N64.89
Original notice
Breast Reduction Surgery and Gynecomastia Surgery (CPB 0017, reviewed 2026-10-26)
aetna.com · Always check the source before changing claims.
Related changes
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