Rule 23-203-4.18 - Reduction MammoplastyA. The Division of Medicaid covers reduction mammoplasty only when there is medical documentation that demonstrates the procedure is: 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. 23 Miss. Code. R. 203-4.18
Miss. Code Ann. §§ 43-13-117, 43-13-121.