aetna breast reduction requirements

Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. The health burden of breast hypertrophy. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. ol.numberedList LI { ASPS clinical practice guideline summary on reduction mammaplasty. 2010;45(3):650-654. 2014a;34(3):409-416. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. background-position: right 65%; Asian J Surg. position: fixed; background-color:#eee; Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. The authors concluded that low-dose radiotherapy to the male breast might be a safe and effective strategy to prevent gynecomastia incidence or recurrence in high-risk patients. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . li.bullet { Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . A population-level analysis of bilateral breast reduction: does age affect early complications? Breast cancer found at the time of breast reduction. Patients with abnormal histopathology could not be pre-operatively identified based on demographics. Level of Evidence = III. Ann Plast Surg. 1. } A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. Plast Reconstr Surg. Aetna considers magnetic resonance imaging (MRI), with or without contrast materials, of the breast medically necessary for members who have had a recent (within the past year) conventional mammogram and/or breast sonogram, in any of the following circumstances where MRI of the breast may affect their clinical management:. 2000;106(2):280-288. 2005;58(3):286-289. Gonzalez FG, Walton RL, Shafer B, et al. Surgical management of gynecomastia--a 10-year analysis. Aesthetic Plast Surg. The authors stated that operative subjects were told that their responses to the questionnaire were not to be used for insurance and thus the subjects had no motivation to exaggerate symptoms prior to surgery in questionnaire responses; however, it is not clear whether operative subjects would be willing to submit responses to a questionnaire from the doctor that differed substantially from the history that they provided to the doctor during their preoperative evaluation. They concluded that higher resection weight, increased BMI, older age, and smoking are risk factors for complication and that patients should therefore be adequately counseled about losing weight and stopping smoking. Plast Reconstr Surg. Compared with the open surgery group, the vacuum-assisted breast biopsy group had significantly smaller scar sizes left after the operation (5.5 1.3 cm versus 0.8 0.2 cm, p < 0.001), and shorter hospital stay time (5.5 2.4 days versus 3.1 1.6 days, p < 0.001). 1995;61(11):1001-1005. top: 0px; Oxfordshire NHS Trust. This Clinical Policy Bulletin may be updated and therefore is subject to change. Breast reduction surgery is considered cosmetic and not medically necessary for the following conditions: poor posture, breast asymmetry, pendulousness, problems with clothes fitting properly and nipple-areola distortion. Obesity and complications in breast reduction surgery: Are restrictions justified? Breast Concerns of Adolescents. } 1991;27(3):232-237. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. In a within-patient, randomized, patient- and assessor-blinded, controlled study, Anzarut et al (2007) evaluated the use of completely autologous platelet gel in 111 patients undergoing bilateral reduction mammoplasty to reduce post-operative wound drainage. Abnormal histopathological findings were more frequent in patients with reduction mammoplasty performed prior to oncological treatment (p < 0.001), and in patients with immediate reconstruction (p = 0.0064). Risk factors for complications following breast reduction: Results from a randomized control trial. In a review on Surgical treatment of primary gynecomastia in children and adolescents, Fischer et al (2014b) concluded that surgical correction of gynecomastia remains a purely elective intervention. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. Initial breast reconstruction including augmentation with implants 15771-15772 (when specific to breast), 19325, 19340, 19342, C1789 Fat grafting (alone, or with implant based feminization) 15771, 15772 *Note: CPT 19318 (breast reduction) includes the work necessary to reposition and reshape the nipple . Refer to the member's specific plan document for applicable coverage. Med Decis Making. The American Society of Plastic Surgeons' evidence-based clinical practice guideline on reduction mammoplasty (ASPS, 2011) states thatin standard reduction mammoplasty procedures, evidence indicates that the use of drains is not beneficial. .fixedHeaderWrap { GP Notebook. These investigators stated that in an era of evidence-based medicine, surgeons performing breast reductions must adopt the results from scientific research into their clinical practice. Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. Resolution of idiopathic gynecomastia may take several months to years. Radiotherapy was shown to significantly reduce the incidence to a median of 23 %, with all 6 RCTs assessed demonstrating a statistically significant decrease in incidence following radiotherapy prophylaxis. Am Surg. list-style-type: decimal; The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. and areola. Imahiyerobo TA, Pharmer LA, Swistel AJ, Talmor M. A comparative retrospective analysis of complications after oncoplastic breast reduction and breast reduction for benign macromastia: Are these procedures equally safe? 2007;356(5):479-485. margin-bottom: 38px; }. Well-designed trials are especially important in assessing pain management interventions to isolate the contribution of the intervention from placebo effects, the effects of other concurrently administered pain management interventions, and the natural history of the medical condition. 1998;49:215-234. 1994;21(3):539-543. This trial included all male patients who presented to the authors breast clinic who were diagnosed with primary gynecomastia, and were treated with a trial of tamoxifen 10 mg daily therapy, over a 10-year period from October 2004 to October 2015. 2015;75(4):370-375. Gland Surg. Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. Gynecomastia: A systematic review. 1997;185(6):593-603. Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. cursor: pointer; The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. Results illustrated that 3050 patients were <60 years of age (39.7 11.8 years) and 487 were 60 years of age (65.1 4.7 years). In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. Among these domains were: vitality, emotional discomfort, limitations due to physical aspects and limitations due to pain. Reduction mammoplasty for asymptomatic members is considered cosmetic. Emiroglu M, Salimoglu S, Karaali C, et al. Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. Pseudo-gynecomastia refers to excessive fat tissue or prominent pectoralis muscles. Plastic Reconstruct Surg. 1995;95(1):77-83. The operative group in the BRAVO study was drawn from a number of surgical practices that volunteered to participate in the study; no details are provided about how each center selected candidates for reduction mammoplasty, or how they chose patients who underwent mammoplasty for inclusion in the study. Women's Health and Cancer Rights Act of 1998. 2002;109(5):1556-1566. 2000;45(6):575-580. Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain. Current concepts in gynaecomastia. Kasielska-Trojan and associates (2018) analyzed digit ratio in relation to estrogen receptor (ER) and progesterone receptor (PR) expression and verified digit ratio (2D: 4D) as a marker of ER and PR over-expression in the male breast. Aetna considers molecular susceptibility testing for breast and/or epithelial ovarian cancer ("BRCA testing") medically necessary once per lifetime in any of the following categories of high-risk adults with breast or epithelial ovarian cancer (adapted from guidelines from the U.S. Preventive Services Task Force (for color: #FFF; Clinical outcomes were measured by operative subjects' responses to a questionnaire about symptoms and quality of life. The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. In other patients, excess skin and nipple and areola relocation are necessary. For the first update of this review, these investigators searched the Cochrane Wounds Group Specialised Register (searched March 4, 2015); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 2); Ovid Medline (2012 to March 3, 2015); Ovid Medline (In-Process & Other Non-Indexed Citations March 3, 2015); Ovid Embase(2012 to March 3, 2015); and EBSCO CINAHL (2012 to March 4, 2015). Policy Statement 6d: Aesthetic surgery procedures. color: red Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). #backTop { In the case of breast reduction, however, for insurance purposes, it . Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass Handschin AE, Bietry D, Hsler R, et al. Pediatr Surg Int. The vacuum-assisted breast biopsy system is an effective strategy for the treatment of gynecomastia. Schnur PL, Hoehn JG, Ilstrup DM, et al. Determinants of surgical site infection after breast surgery. Aetna considers breast reconstructive surgery to correct breast asymmetry cosmetic except for the following conditions: Surgical correction of chest wall deformity causing functional deficit in Poland syndrome when criteria are met in CPB 0272 - Pectus Excavatum and Poland's Syndrome: Surgical Correction; or Kinell I, Baeusang-Linder M, Ohlsen L. The effect on the preoperative symptoms and the late results of Skoog's reduction mammoplasty: A follow-up study on 149 patients. Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). 2014;20(3):274-278. The average age of the studied individuals was 25.7 years (SD = 7.8); ER and PR expression was detected in breasts, and digit ratios were calculated in patients with idiopathic gynecomastia. Gynecomastia is a very common concern of male adolescence. A systematic search of the published literature was performed. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. (25 y/o female with a 38J bra size) according to aetna, I should more than qualify for a reduction as I have back, neck, shoulder pain, chest pain and pressure, arm numbness while laying on sides, etc. This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. While the efficacy of radiotherapy as a therapeutic modality for gynecomastia was also established, it was shown to be less effective than other available options. Fan L, Yang X, Zhang Y, Jiang J. Endoscopic subcutaneous mastectomy for the treatment of gynecomastia: A report of 65 cases. A study by Bruhlmann and Tschopp (1998) was a retrospective study of 246 patients from a surgical practice, approximately 50 % (132) of whom returned a questionnaire about their symptoms and satisfaction with aesthetic results, and their recollection of symptoms prior to surgery. hr.separator { Gynecomastia has been classified into2 types. Hello! Li CC, Fu JP, Chang SC, et al. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. Fagerlund A, Cormio L, Palangi L, et al. Also, there was no correlation between PR expression and 2D: 4D. the nipple-areola complex can be elevated by de-epithelialization rather than recreating or developing a new pedicle; breast tissue is removed where it is in excess, usually inferiorly and laterally; the resection is complemented with liposuction to elevate the bottomed-out inframammary fold; and. Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. 2018;24(6):1043-1045. 40 . text-decoration: line-through; Nelson et al (2014a) analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. The following procedures are considered experimental and investigational because there is insufficient evidence of itseffectiveness or itseffectiveness has not been established: Aetna considers breast reduction, surgical mastectomy or liposuction for gynecomastia, either unilateral or bilateral, a cosmetic surgical procedure. Ages ranged from 18 to 66 years. 1993;91(7):1270-1276. Surgical removal is rarely indicated and the vast majority of the time is for cosmetic reasons, as there is no functional impairment associated with this disorder. 1999;103(6):1682-1686. of the following criteria must be met: 1998;41(3):240-245. } 2003;111(2):688-694. } The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. Another set of breast pump supplies if you get pregnant . A follow-up study of 105 women with breast cancer following reduction mammaplasty. Type II gynecomastia is more generalized breast enlargement. The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. Furthermore, the lack of an expected "dose-response" relationship between the amount of breast tissue removed and the magnitude of symptomatic relief in these studies raises questions about the validity of these studies and the effectiveness of breast reduction as a method of relieving shoulder and back pain. You first need to demonstrate that the procedure is "medically necessary and therefore reconstructive rather than cosmetic," says board-certified New York City plastic surgeon Dr. Umbareen Mahmood. In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. 1990;24(1):61-67. Subjects were compared to age-matched norms from another study cohort. He and associates (2011) examined the safety and feasibility of vacuum-assisted biopsy device in the treatment of gynecomastia. Setala L, Papp A, Joukainen S, et al. These studies did not find a relationship between breast weight or amount of breast tissue removed and the likelihood of response or magnitude of relief of pain after reduction mammoplasty. margin-top: 38px; If an insufficient amount of breast tissue is removed, the surgery is less likely to be successful in relieving pain and any related symptoms from excessive breast weight (e.g., excoriations, rash). The surgeon estimates that at least the following amounts (in grams) of breast tissue, not fatty tissue, will be removed from each breast, based on the member's body surface area (BSA) calculated using theMosteller formula. I have recently met with my primary doctor after speaking to my insurance company (aetna) for months about getting a breast reduction. list-style-type: upper-alpha; Hoyos and colleagues (2021) stated that male chest definition surgery and patients complaining of breast tissue over-growth have been increasing in recent decades. z-index: 99; Miller AP, Zacher JB, Berggren RB, et al. In these cases, breast reduction for men may take 2 to 3 hours. Several important points should be considered in evaluating these challenges to insurers' criteria for breast reduction surgery. It's important to note that CPT 19324 - mammaplasty, augmentation without pros-thetic implant - has been deleted. outline: none; } Radiotherapy for prevention or management of gynecomastia recurrence: Future role for general gynecomastia patients in plastic surgery given current role in management of high-risk prostate cancer patients on anti-androgenic therapy. Please check your insurance policy to see whether breast reduction is a covered procedure. } The member has gigantomastia of pregnancy accompanied byany of the following complications, and delivery is not imminent: For medical necessity criteria for surgery to correct breast asymmetry, seeCPB 0185 - Breast Reconstructive Surgery. A lack of correlation between these variables may result from the fact that the analyzed group of men with idiopathic gynecomastia was small in number, but at the same time, it appeared to be homogenous in these aspects (positive ER and/or PR expression and high digit ratio). This was further isolated when comparing morbidly obese patients to non-obese (p < 0.001), class I (p < 0.001), and class II (p = 0.01) patients. Aetna and the City shall each abide by all applicable laws, regulations and government requirements regarding the confidentiality and the safeguarding of individually identifiable health and other personal information, including the privacy and security requirements of HIPAA. Plast Reconstr Surg. Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. Nelson et al (2014b) separately conducted a population level analysis of the 2005-2011 NSQIP datasets, identifying patient who underwent reduction mammoplasty, to determine the impact of obesity on early complications after reduction mammoplasty. color: blue!important; Grooving where the bra straps sit on the shoulder. Aesthetic Plast Surg. list-style-type: upper-roman; color:#eee; Most UnitedHealthcare plans have a specific exclusion for breast reduction surgery except as required by the . Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Jones SA, Bain JR. Review of data describing outcomes that are used to assess changes in quality of life after reduction mammaplasty. The surgeon must also certify that a certain weight of breast tissue (based on Aetna's table) will be removed in every breast, and not entirely fatty tissue. 2015;10(8):e0136094. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. There are alsoseveral earlier, smaller studies that found reductions in symptoms and improvements in quality of life after reduction mammoplasty (Glatt et al, 1999; Bruhlmannand Tschopp, 1998; Blomqvist et al, 2000; and Behmand et al, 2000). Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammaplasty. You may be able to buy a breast pump and supplies from one of our medical equipment suppliers at no charge or at a discounted rate. See Appendix for Table 1. ul.ur li{ Gynecomastia. There were no restrictions on the basis of date or language of publication. color: white; The authors concluded that the vacuum-assisted breast biopsy system could be used as a feasible and minimally invasive approach for the treatment of gynecomastia. No data were provided on loss to follow-up. Some individuals, however, have argued that reduction mammoplasty may be indicated in any woman who suffers from back and shoulder pain, regardless of how small her breasts are or how little tissue is to be removed (ASPS, 2002). Level of Evidence = IV. A physician-supervised diet and exercise plan may be indicated in obese patients. Scand J Plast Reconstr Hand Surg. Brown DM, Young VL. Horm Res Paediatr. } Approximately 25 % of the 49 subjects included in this study did not return the post-operative questionnaire. list-style-type: lower-alpha; 1969;44(235):291-303. There were no statistically significant differences between the 2 vacuum-assisted breast biopsy systems according to the mean age, the mean operation time, sites, or grade. For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. 2008;121(4):1092-1100. Breast reduction surgery, also known as reduction mammaplasty, removes fat, breast tissue and skin from the breasts. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. Leclere FM, Spies M, Gohritz A, Vogt PM. The investigators found little difference between obese and non-obese women concerning patient's reports of resolution of symptoms and improvement in body image. In the case of reduction mammoplasty for relief of back, neck and shoulder pain, Aetna has considered this procedure medically necessary in women with excessively large breasts because it seems logical, even in the absence of firm clinical trial evidence, that this excessive weight would contribute to back and shoulder pain, and that removal of this excessive breast tissue would provide substantial pain relief, reductions in disability, and improvements in function. cursor: pointer; Criteria for reduction mammoplasty surgery from the American Society of Plastic Surgeons (ASPS, 2002; ASPS, 2011) states, among other things, that breast weight or breast volume is not a legitimate criterion upon which to distinguish cosmetic from functional indications. border-width:0; World J Surg. The control group was not followed longitudinally or treated according to any protocol to ensure that they received optimal conservative management; conclusions about the lack of effectiveness of conservative management were based on their responses to a questionnaire about whether subjects tried any of 15 conservative interventions, and whether or not they thought these interventions provided relief of symptoms. A total of 81 patients were included in this study. Breast reduction surgery might also help improve self-image and the ability to take part in physical activities. They also analyzed if timing of reduction mammoplasty in relation to oncological treatment influenced the incidence of abnormal findings, and compared if patients with abnormal contralateral histopathology differed from the study population in terms of demographics. The following factors were independently associated with any surgical complications: morbid obesity (odds ratio [OR], 2.1; P < .001), active smoking (OR, 1.7; P < .001), history of dyspnea (OR, 2.0; P < .001), and resident participation (OR, 1.8; P = .01) while factors associated with major complications included active smoking (OR, 2.7; P < .001), dyspnea (OR, 2.6; P < .001), resident participation (OR, 2.1; P < .001), and inpatient surgery (OR, 1.8; P = .01). In: Townsend CM, Beuchamp RD, Evers BM, eds. Surgery. Wound drainage after plastic and reconstructive surgery of the breast. Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: A review. The goals of the surgery are to relieve symptoms caused by heavy breasts, to create a natural, balanced appearance with normal location of the nipple and areola, to maintain the capacity for lactation and allow for future breast exams/mammograms with minimal scarring or decreased sensation. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. Surgeon. Sabistons Textbook of Surgery (Burns & Blackwell, 2008)states that breast size should be stable for one year: There is no set lower age limit but, for the adolescent with breast hypertrophy, reduction is deferred until the breasts have stopped growing and are stable in size for at least 12 months before surgery.. Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. Data were prospectively gathered on complications as a part of randomized control trial (RCT) examining psycho-socialand quality of life(QOL) benefits of reduction mammoplasty. Arlington Heights, IL: ASPS; 2011. For medical Prepubertal gynecomastia linked to lavender and tea tree oils. Washington, DC: ACOG; 2011:121-122. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). The authors concluded that breast re-reduction can be performed safely and predictably, even when the previous technique is not known; and 4 key principles were developed: Language services can be provided by calling the number on your member ID card. 2006;118(4):840-848. All the patients recovered well and were satisfied with the cosmetic outcomes. Reduction mammoplasty for macromastia. Plastic Reconstr Surg. Krieger LM, Lesavoy MA. Secondary outcomes included subjective as well as objective assessments of pain and wound healing. } Arlington Heights, IL: ASPS; May 2011. } Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. Aetna considers breast reduction surgery medically necessary for non-cosmetic indications for women aged 18 or older or for whom growth is complete (i.e., breast size stable over one year) when any of the following criteria (A, B, or C) is met: Macromastia: all of the following criteria must be met: You must be at least 18 years old or show completed breast growth (no change in breast size over at least a year) to qualify for Aetna breast reduction coverage. Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). The nipple-areola complex was re-positioned in 60 % of patients (n = 54). 2015;49(6):311-318. 1999;103(6):1687-1690. Nelson JA, Fischer JP, Chung CU, et al Obesity and early complications following reduction mammaplasty: An analysis of 4545 patients from the 2005-2011 NSQIP datasets. 2015;(10):CD007258. A cohort study of breast cancer risk in breast reduction patients. Risk of bias was assessed independently by 2review authors. background-color: #cc0066; Surg Laparosc Endosc Percutan Tech. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. Endocrinol Metab Clin North Am. In this study the National Surgical Quality Improvement Program data set was queried for the Current Procedural Terminology code 19318 from the years 2005 to 2010, with principal outcome measurements of wound complications, surgical site infections, and reoperations.

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