Cigna modified MM 0152 for breast reduction surgery (reduction mammoplasty), effective November 15, 2025. Here's what billing teams need to know before claims go out the door.
Cigna Healthcare updated its coverage position criteria under MM 0152 in the Cigna breast reduction coverage policy, covering CPT 19318 (breast reduction) and CPT 19316 (mastopexy) for symptomatic macromastia and contralateral breast procedures following mastectomy or lumpectomy. Two additional codes — CPT 15839 and CPT 19355 — are explicitly designated cosmetic and not medically necessary. And two codes, CPT 15877 and CPT 19350, are considered integral to the primary procedure and will not be separately reimbursed. If your practice bills plastic surgery, general surgery, or oncologic reconstruction, this policy directly affects your charge capture and claim denial risk.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Cigna Healthcare |
| Policy | Breast Reduction — Reduction Mammoplasty for Macromastia |
| Policy Code | MM 0152 |
| Change Type | Modified |
| Effective Date | November 15, 2025 |
| Impact Level | High |
| Specialties Affected | Plastic Surgery, General Surgery, Breast Surgery, Oncologic Reconstruction |
| Key Action | Audit charge capture for CPT 15877 and 19350 — both are bundled under this policy and will not pay separately |
Cigna Breast Reduction Coverage Criteria and Medical Necessity Requirements 2025
The MM 0152 Cigna system coverage policy draws a sharp line between two clinical scenarios: breast reduction for symptomatic macromastia and breast surgery on the contralateral (non-diseased) breast after mastectomy or lumpectomy. Both can qualify as medically necessary under the right conditions. Neither is automatically covered.
For symptomatic macromastia, Cigna evaluates medical necessity based on documented functional impairment. Think chronic back, neck, or shoulder pain, skin breakdown, or nerve symptoms — not patient preference or aesthetic concerns. The documentation burden here is real. If your surgeons aren't providing detailed clinical notes that tie symptoms directly to breast hypertrophy, you're setting up for a claim denial before the case even starts.
For the contralateral breast, the policy addresses procedures performed on the non-diseased side to achieve symmetry after a mastectomy or lumpectomy. This is a separate clinical and coverage track. The applicable codes here can still be CPT 19316 or CPT 19318, but the documentation requirements and coverage rationale differ from the macromastia pathway.
Prior authorization is a near-certainty for breast reduction billing under Cigna. Given that Cigna explicitly defines medical necessity criteria in this policy, expect that any claim for CPT 19316 or CPT 19318 without documented prior authorization approval — and without supporting clinical criteria — will not survive adjudication. Check the patient's specific Cigna plan before scheduling. Some fully-insured plans carry additional exclusions for breast reduction regardless of medical necessity status.
Whether Cigna breast reduction reimbursement is available for a given patient depends heavily on plan type. Self-funded employer plans can — and often do — exclude procedures like reduction mammoplasty even when medical necessity criteria are met. Verify benefits before the procedure, not after.
Cigna Breast Reduction Exclusions and Non-Covered Indications
Two codes in this policy carry explicit cosmetic designations. Cigna considers CPT 15839 (excision of excessive skin and subcutaneous tissue, other area) and CPT 19355 (correction of inverted nipples) cosmetic and not medically necessary under MM 0152.
If either of these codes appears on your charge sheet alongside CPT 19318, pull them. Billing CPT 15839 or CPT 19355 on the same claim as a breast reduction procedure won't just result in denial of those specific lines — it can flag the entire claim for review. That's a problem worth avoiding.
The real issue here is charge capture hygiene. Templates built for breast surgery procedures sometimes auto-populate adjacent codes. Review your encounter templates and make sure CPT 15839 and CPT 19355 are not default additions to reduction mammoplasty charge sets.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Breast reduction for symptomatic macromastia | Covered (when medical necessity criteria met) | CPT 19318 | Prior authorization required; document functional symptoms |
| Mastopexy for symptomatic macromastia or contralateral symmetry | Covered (when medical necessity criteria met) | CPT 19316 | Prior authorization required; plan exclusions may apply |
| Contralateral breast surgery after mastectomy/lumpectomy | Covered (when criteria met) | CPT 19316, CPT 19318 | Symmetry procedures on non-diseased breast; document surgical history |
| Nipple/areola reconstruction (as part of primary procedure) | Integral — not separately reimbursed | CPT 19350 | Bundled; do not bill separately |
| Suction-assisted lipectomy of trunk (as part of primary procedure) | Integral — not separately reimbursed | CPT 15877 | Bundled; do not bill separately |
| Excision of excessive skin, other area | Cosmetic / Not Medically Necessary | CPT 15839 | Will deny; remove from charge templates |
| Correction of inverted nipples | Cosmetic / Not Medically Necessary | CPT 19355 | Will deny; remove from charge templates |
Cigna Breast Reduction Billing Guidelines and Action Items 2025
These are the steps your billing and revenue cycle team should take before November 15, 2025.
| # | Action Item |
|---|---|
| 1 | Audit your charge capture templates now. Pull every charge template that includes CPT 19318 or CPT 19316. Check whether CPT 15839, CPT 19355, CPT 15877, or CPT 19350 appear as defaults or add-ons. Remove CPT 15839 and CPT 19355 entirely from breast reduction charge sets. Flag CPT 15877 and CPT 19350 as bundled — they do not bill separately under Cigna's MM 0152 policy. |
| 2 | Verify prior authorization requirements for every scheduled case. Cigna requires that medical necessity criteria are met before reimbursement. For CPT 19318 and CPT 19316, confirm prior authorization is in place before the case is performed. If your team is calling Cigna to verify benefits, ask specifically whether the patient's plan excludes reduction mammoplasty — self-funded plans vary widely. |
| 3 | Review documentation standards with your surgical team. Claims for CPT 19318 under the macromastia pathway need clinical records that connect the patient's symptoms — back pain, skin rash, nerve compression, postural problems — directly to breast hypertrophy. Generic notes don't hold up on appeal. Get specific measurements, symptom duration, and conservative treatment history into the operative note and pre-authorization request. |
| 4 | Separate contralateral breast claims from macromastia claims in your workflow. These are different coverage tracks under MM 0152. A patient who had a mastectomy and is now getting a symmetry procedure on the other breast needs documentation of the prior oncologic surgery, not a macromastia symptom history. Make sure your billing team knows which clinical scenario applies before coding the claim. |
| 5 | Update your denial management queue. Any denial on CPT 19316 or CPT 19318 for Cigna patients should route to staff who understand the MM 0152 criteria. Appeals need to reference the specific coverage criteria in this policy and include the clinical documentation that supports medical necessity. Generic appeal letters won't move these. |
| 6 | Talk to your compliance officer if your volume is high. If your practice performs significant breast surgery volume and bills Cigna, the effective date of November 15, 2025 is a hard cutoff. Claims submitted after that date are adjudicated under the modified policy. If you're not certain how this intersects with your payer mix, your contract terms, or your current documentation practices, loop in your compliance officer or billing consultant before that date. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Breast Reduction Under MM 0152
Covered CPT Codes (When Medical Necessity Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 19318 | CPT | Breast reduction |
| 19316 | CPT | Mastopexy |
Bundled Codes — Integral to Primary Procedure, Not Separately Reimbursed
| Code | Type | Description | Notes |
|---|---|---|---|
| 15877 | CPT | Suction assisted lipectomy; trunk | Considered integral to primary procedure; will not pay separately |
| 19350 | CPT | Nipple/areola reconstruction | Considered integral to primary procedure; will not pay separately |
Not Covered — Cosmetic / Not Medically Necessary
| Code | Type | Description | Reason |
|---|---|---|---|
| 15839 | CPT | Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area | Considered cosmetic / not medically necessary under MM 0152 |
| 19355 | CPT | Correction of inverted nipples | Considered cosmetic / not medically necessary under MM 0152 |
No HCPCS Level II codes or ICD-10-CM codes are listed in the MM 0152 policy data for this update.
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