Weight Criteria For Breast Reduction

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SURG.00086 VA 10-01-2008 V2 8-18
(weight) of breast tissue to be who are anticipated to have at least 1 kg. of breast tissue removed from each breast and who meet the following criteria: Presence of one or more of the following that has Breast reduction surgery is considered not medically necessary for ... Access Full Source

Services For Which Predeterminations Can Be Requested
Breast Reduction - Reduction Mammaplasty for Systematic Breast Hypertrophy or height and weight • Letter of Medical Necessity including documented 5 year history of obesity providing it otherwise meets medical necessity criteria. Medical Policy Reference: RAD605.001 ... Access Content

Criteria For Coverage Of Bilateral Breast Reduction ...
Should breast reduction mammoplasty surgery be deemed medically necessary, all of the weight, height and BMI. STEP 2: Criteria for Pre-Approval of Surgery The surgical specialist agrees, in writing, that the reduction mammoplasty is medically ... Document Retrieval

BREAST ASYMMETRY/BREAST REDUCTION ASSESSMENT FORM
BREAST ASYMMETRY/BREAST REDUCTION ASSESSMENT FORM is eligible for consideration of NHS funded Breast Asymmetry or Breast Reduction Surgery in line with the eligibility criteria set out in the Commissioning Policy for Patients Current Weight: Patients BMI: Clinical Information/Reason for ... Doc Retrieval

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BENEFITS INDEX - Molina Healthcare
Molina Healthcare of Ohio, Inc., P.O. Box 349020, Columbus, OH 43234-9020 Breast reduction deemed medically necessary as a result of Must meet specific criteria and is limited to one hearing aid per four years for adults. ... View This Document

STATE OF MICHIGAN
Implant and reduction of the right breast to eliminate the back pain and achieve symmetry. percentile cutoff weight for body surface area The IRO reviewer also concluded that the Petitioner did not meet the criteria of the “Breast Reduction (Reduction Mammoplasty) ... Return Document

Reduction Mammaplasty For Women Pre-Authorization: Yes Page 1 ...
Provides coverage for breast reduction when ALL of the following criteria are met: criteria: a. Pain in upper back, percentile on the Schnur Sliding Scale for body surface area and weight of breast tissue to be removed. ... Retrieve Content

Commissioning Guide : breast reduction Surgery
Excised breast weight of 500 grams and upwards Patients who do not meet the criteria • Offer the option to review their case in future. Commissioning guide 2014 Breast reduction surgery 9 College of Surgeons of England ... Retrieve Content

Reduction Mammoplasty
The following protocol contains medical necessity criteria for Reduction Mammoplasty Schnur sliding scale: Schnur Sliding Scale. Breast Weight (g) Body Surface Area (in meters squared)* Lower 5% Lower 22%; 1.35 ; 199 ; 127 . 1.40 : 218 . 139 : Schnur Sliding Scale Breast Weight (g) Body ... Fetch Content

Tips On Getting Your Plastic Surgery Approved
My belief is that the primary goal of plastic surgery after weight loss is to restore may also have wide variation in the criteria they use for approval the main plastic surgery procedures covered are going to be breast reduction and abdominoplasty. Things like arm and leg lifts ... View This Document

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The Practical Guide
The Practical Guide will be distributed to primary care physicians, nurses, breast, prostate, and colon.14 Higher achieve weight reduction and how to maintain a lower body weight. ... Doc Viewer

Provider Data Submission Tool Based On Anthem Corporate ...
_____Request is for the use of liposuction to perform a breast reduction. Member’s weight:_____ Size and shape of the breasts:_____ Anticipated amount of breast tissue to be removed: _____ Please send in front and lateral view ... Document Retrieval

Breast Related Procedures - Priority Health
Breast reduction removing less than 350 grams from a breast is considered a cosmetic procedure and is not a covered benefit. e. (MRI of the Breast) for criteria (www.americanimaging.net). III. Excessive breast weight may be reduced through a weight reduction management ... Retrieve Document

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Reduction Mammoplasty (Bilateral) PA Form - Priority Health
Patient must meet all criteria under Criteria Set A or Criteria Set B. Criteria breast reduction removing less than 350 grams from a breast is considered a cosmetic procedure Body surface area and cutoff weight of average breast tissue removed Body Surface Area (m. 2) Body Surface Area (m ... Read Here

Last Review Status/Date - FEP Blue
Last Review Status/Date: March 201 4 be based on patients’ self-reported symptoms rather than more objectively measured criteria, such as weight of excised breast tissue. and quality of life benefits of bilateral breast reduction surgery. Br J Surg 2006; 93(3):291-4. ... Return Doc

Medical Policy Updates - MVP Health Care
Breast Reduction Surgery (Reduction Mammaplasty): The Indications/Criteria section now states that the minimum amount of breast tissue (in grams) to be removed is determined by the member’s changes to Medicare criteria regarding weight requirements. ... Retrieve Full Source

Physician’s Name And Address Date [Attn: Claims Department]
Weight of their excess breast volume. The justification for reduction mammaplasty should be based The criteria for reduction mammaplasty are more accurately defined by individual symptomatology rather than breast resection weight alone. ... Fetch Document

REDUCTION MAMMAPLASTY History And Physical ... - BCBSTX
REDUCTION MAMMAPLASTY SUR716.012 _____ COVERAGE: Coverage WILL NOT BE ALLOWED for Reduction Mammaplasty increase in the volume and weight of breast tissue in excess of the normal proportion. Breast hypertrophy may affect one or more of the body systems, ... Fetch This Document