Current through September 24, 2024
A. The Division of
Medicaid covers reduction mammoplasty only when there is medical documentation
that demonstrates the procedure is:
1.
Medically necessary,
2.
Reconstructive, and
3. Performed
as a last means of attempting to alleviate a beneficiary's symptomatology and
dysfunction due to the excessive breast size.
B. The Division of Medicaid covers reduction
mammoplasty only when there is documentation that the beneficiary meets all of
the following:
1. If under the age of
eighteen (18), has been evaluated by the primary care provider and the primary
care provider has documented that:
a) The
beneficiary is appropriate for this procedure,
b) Has reached the age of sixteen (16) and/or
Tanner Stage V of the Tanner Staging of Sexual Maturity Rating, and
c) The primary care provider agrees that the
beneficiary is appropriate for a surgical evaluation for reduction mammoplasty.
2. Has maintained a
stable weight for the past two (2) years.
C. Justification for reduction mammoplasty
must be based on the probability of relieving clinical signs and symptoms of
macromastia. The surgeon's documentation must include the following criteria:
1. A complete and accurate beneficiary
history that includes complaints of pain, restriction of normal activity and
stable weight for the past two (2) years.
2. Medical necessity for the removal of a
minimum of five hundred (500) grams of tissue from each breast. If the removal
of the amount of breast tissue is less than five hundred (500) grams, the
surgeon must provide full documentation in the medical record that justifies
reduction mammoplasty with removal of less than five hundred (500) grams.
3. Supra sternal notch to nipple
measurement of twenty-eight (28) cm or greater.
4. Frontal and lateral photographs of the
breasts.
D. In addition
to the criteria listed in Miss. Admin. Code Part 203, Chapter 4, Rule 4.18.C.,
documentation of the following may support the determination of medical
necessity:
1. A history of intertrigo under
or between breasts,
2. A
psychological assessment, and/or
3. Documentation of deep grooves over the
shoulders from bra straps as evidenced in photographs.
E. The surgeon must retain all documentation
supporting medical necessity in the medical record.
Miss. Code Ann.
§§
43-13-117,
43-13-121.
