aetna breast reduction requirements

Fagerlund A, Lewin R, Rufolo G, et al. Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. 1998;26(1):61-65. 2006;9(2):109-114. Study subjects included 3538 patients with an average age of 43 years and body mass index of 31.6 kg/m(2) and most patients underwent outpatient surgery (80.5%) with an average operative time of 180 minutes.The incidence of overall surgical complications was 5.1% and the incidence of major surgical complications was 2.1%. } Drainage in breast reduction surgery: A prospective randomised intra-patient trail. Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. .strikeThrough { Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . Nguyen JT, Wheatley MJ, Schnur PL, et al. Leclere FM, Spies M, Gohritz A, Vogt PM. (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) 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). Horm Res Paediatr. } Grooving where the bra straps sit on the shoulder. Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. A physician-supervised diet and exercise plan may be indicated in obese patients. To get insurance coverage, you'll probably need . Philadelphia, PA: WB Saunders Company; 2008; Ch 73. Li CC, Fu JP, Chang SC, et al. Subjects were compared to age-matched norms from another study cohort. 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: 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). 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. Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. A detailed physical examination, including testicular examination. Plast Reconstr Surg. Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. The average interval between primary and secondary surgery was 14 years (range of 0 to 42 years). Gynecomastia may be drug-induced. 1999;103(6):1674-1681. Gynecomastia in patients with prostate cancer: A systematic review. A detailed drug history, including list of medications, an assessment of indirect or environmental exposure to estrogenic compounds, and recreational drug use. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. Burns JL, Blackwell SJ. color: blue!important; For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. 2020 Sep 4 [Online ahead of print]. In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. 2010;45(3):650-654. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. 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. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. 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. In fact, according to the American Society of Plastic Surgeons, more than 46,000 breast reduction procedures were performed in 2019, a six percent increase compared to 2018; but in recent years, insurance companies have become more likely to deny coverage for this medically recommended procedure. Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. Plast Reconstr Surg. Although operative subjects were examined before and after surgery, there was no attempt to employ any blinded or objective measures of disability and function to verify these self-reports. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. These investigators searched the literature on the treatment of Simon's grade I and II gynecomastia in PubMed, Scopus, Science Direct, and Cochrane using keywords "gynecomastia" and "liposuction". Management of gestational gigantomastia. The risks included infection, wound breakdown, scarring, and the need for re-operating. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. 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.. There were no restrictions on the basis of date or language of publication. ER expression did not correlate with the right (p = 0.51) and left 2D: 4D (p = 0.97). World J Surg. Ann Plast Surg. Chadbourne EB, Zhang S, Gordon MJ, et al. Kerrigan CL, Collins ED, Kim HM, et al. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. Management of gynecomastia should include evaluation, including laboratory testing, to identify underlying etiologies. Reduction mammaplasty. A non-standardized survey showed a very high satisfaction index. Plastic Reconstruct Surg. background: #5e9732; 2007;119(4):1159-1166. Reduction mammaplasty: An outcome study. The safety, efficacy, complications, and patient satisfactions were recorded during post-operative follow-up periods. In addition, Nguyen et al (2004) ignored a wealth of published evidence of the effectiveness of physical therapy, analgesics and other conservative measures on back and neck pain generally. 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. 2000;45(6):575-580. background-color: #663399; A cohort study of breast cancer risk in breast reduction patients. 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 . Emiroglu M, Salimoglu S, Karaali C, et al. Guidelines for Adolescent Health Care. 1969;44(235):291-303. Aesthetic Plast Surg. Autorino R, Perdona S, D'Armiento M, et al. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. border-width:0; Arlington Heights, IL: ASPS; May 2011. 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. Schnur subsequently refuted the validity of the Schnursliding scaleand stated that thescale should no longer be used as a criterion for the determination of insurance coverage for breast reduction surgery (Nguyen et al, 1999). Variations in pattern of pubertal changes in girls. The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. I have recently met with my primary doctor after speaking to my insurance company (aetna) for months about getting a breast reduction. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. Alternatively, you may qualify if your breast size causes significant symptoms, such as: Long-term neck, shoulder or neck pain. ASPS Recommended Coverage Criteria for Third Party Payors. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. This will be computed based on your body area. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. Hoyos and colleagues (2021) stated that male chest definition surgery and patients complaining of breast tissue over-growth have been increasing in recent decades. Treating providers are solely responsible for medical advice and treatment of members. Note: Breast reduction surgery will be considered medically necessary for women meeting the symptomatic criteria specified above, regardless of BSA, with more than 1 kg of breast tissue to be removed per breast. These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. 2019;166(5):934-939. } The authors concluded that the limited evidence available showed no significant benefit of using post-operative wound drains in reduction mammoplasty, although LOS may be shorter when drains are not used. J Plast Reconstr Aesthet Surg. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. Reduction mammoplasty for asymptomatic members is considered cosmetic. 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. Reduction mammaplasty provides long-term improvement in health status and quality of life. Plast Reconstr Surg. } Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. 1993;91(7):1270-1276. In a Cochrane review, Khan and colleagues (2015) stated that wound drains are often used after plastic and reconstructive surgery of the breast in order to reduce potential complications. In the case of breast reduction, however, for insurance purposes, it . The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability. A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. Am J Infect Control. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. Plast Reconstr Surg. 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). z-index: 99; Tang CL, Brown MH, Levine R, et al. 2005;58(3):286-289. It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. J Plast Surg Hand Surg. Third, reliable evidence is especially important for pain interventions, because of the waxing and waning nature of pain and the susceptibility of this symptom to placebo effects and other biases that may confound interpretation of study results. Recommended criteria for insurance coverage of reduction mammoplasty. Within this study population, 54.4% of patients were obese (BMI > 30 kg/m2), of which 1308 (28.8%) were Class I (BMI = 30-34.9 kg/m2), 686 (15.1%) were Class II (BMI = 35-39.9 kg/m2), and 439 (9.7%) were Class III (BMI > 40 kg/m2). The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. } 2008;61(5):493-502. Seitchik MW. The average amount of breast tissue removed ranged from 430 g per breast to 1.6 kg per breast, with increased body weight associated with an increased amount of breast tissue to be removed. As explained below, the studies used to support the arguments for the medical necessity of breast reduction surgery are poorly controlled and therefore subject to a substantial risk of bias in the interpretation of results. Qu S, Zhang W, Li S, et al. Principles of breast re-reduction: A reappraisal. Surgery. Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. Gynecomastia has been classified into2 types. 2018;7(Suppl 1):S70-S76. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. .newText { Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Although the BRAVO study nominally included a "control group", there was no comparison group of subjects selected from the same cohort, who were randomized or otherwise appropriately assigned to reduce bias, and treated with conservative management according to a protocol to ensure optimal conservative care. 2006;118(4):840-848. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. The primary outcome was the difference in wound drainage over 24 hours. Breast reduction, also known as reduction mammaplasty, is a procedure to remove excess breast fat, glandular tissue and skin to achieve a breast size more in proportion with your body and to alleviate the discomfort associated with excessively large breasts (macromastia). Reduction mammoplasty: Criteria for insurance coverage. It was also found that only 3 % of subjects reported that they had no aesthetic motivation for surgery. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. 1998;49:215-234. Surgeon. 2001;107(5):1234-1240. 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 The authors specified the value of these study results was in the identification of morbid obesity as a significant predictor of overall morbidity and active smoking as a strong predictor of major surgical morbidity. /*margin-bottom: 43px;*/ # color: white; padding: 10px; 1995;95(1):77-83. ol.numberedList LI { The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. 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. Secondary outcomes included subjective as well as objective assessments of pain and wound healing. To calculate body surface area (BSA) see:BMI and BSA (Mosteller) Calculator;orBSA (m2) = ([height (in) x weight (lb)]/3131)(denotes square root), BSA (m2) = ([height (cm) x weight (kg)]/3600)(denotes square root). Exposure to partners using estrogen containing vaginal creams; Cancer chemotherapy (alkylating agents, methotrexate, vinca alkaloids, imatinib, combination chemotherapy), Androgen receptor blockers - bicalutamide, 5 reductase inhibitors - finasteride, dutasteride, Angiotensin converting enzyme inhibitors (captopril, enalapril), Calcium channelblockers(diltiazem, nifedipine, verapamil), Anabolic steroids(e.g., in body builders). Tang CL, Brown MH, Levine R, et al. background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; Patients undergoing surgery for gynecomastia should know that their scars may be visible when they are shirtless. 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. 2007;356(5):479-485. They stated that in the light of these findings, contralateral reduction mammoplasty with histopathological evaluation in breast cancer patients offered a sophisticated tool to catch those patients whose contralateral breast needs increased attention. Special Clinical Concerns. 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. Breast reduction surgery might also help improve self-image and the ability to take part in physical activities. Plast Reconstr Surg. 2010;125(5):1301-1308. Breast hypertrophy. Plastic Reconstr Surg. The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 %)]. 2001;76(5):503-510. Other just require 500 grams no matter what your height and weight. 1993;17(3):211-223. Gynecomastia: Evolving paradigm of management and comparison of techniques. padding-right: 18px; 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). Abnormalities in Adolescent Breast Development. 40 . .arrowPurpleSmall, a:hover.arrowPurpleSmall { Karamanos et al (2015) identified their study as the largest sample on breast reduction in the literature, in which age and surgeon specialty did not correlate with negative results. A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery. Well-designed, prospective, controlled clinical studies have not been performed to assess the effectiveness of surgical removal of modest amounts of breast tissue in reducing neck, shoulder, and back pain and related disability in women. With the majority of BBRs performed as an inpatient procedure, there was a trend towards less drain usage in surgeons performing this procedure as an out-patient; however, this was not statistically significant (p = 0.07). 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. Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain. The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. li.bullet { 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). The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. Plast Reconstr Surg. 2002;109(5):1556-1566. Please check your insurance policy to see whether breast reduction is a covered procedure. However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. color: blue #backTop { Mannu GS, Sudul M, Bettencourt-Silva JH, et al. color: #FFF; Apart from a significantly shorter LOS for those participants who did not have drains (MD 0.77; 95 % CI: 0.40 to 1.14), there was no statistically significant impact of the use of drains on outcomes. Howrigan P. Reduction and augmentation mammoplasty. Ann Plast Surg. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). list-style-type: upper-roman; 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). 2012;69(5):510-515. The investigators found little difference between obese and non-obese women concerning patient's reports of resolution of symptoms and improvement in body image. Risk of bias was assessed independently by 2review authors. Wound drainage after plastic and reconstructive surgery of the breast. A systematic search of the published literature was performed. Aesthet Plastic Surg. 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. In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. 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. These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). 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. Drugs commonly associated with the development of gynecomastia include amphetamines, marijuana, mebrobamate, opiates, amitriptyline, chlordiazepoxide, chlorpromazine, cimetidine, diazepam, digoxin, fluphenazine, haloperidol, imipramine, isoniazid, mesoridazine, methyldopa, perphenazine, phenothiazines, reserpine, spironolactone, thiethylperazine, tricyclic antidepressants, tirfluoperazine, trimeparazine, busulfan, vincristine, tamoxifen, , methyltestosterone, human chorionic gonadotropins, and estrogens. Flancbaum L, Choban PS. 2011;128(4):243e-249e. A total of 182 thirty-day postoperative surgical complications were documented, but stratifying patients into 2 age groups did not reveal an association between age and any surgical complication (P = .26). Many men with breast enlargement are found to have pseudo-gynecomastia. Two review authors undertook independent data extraction of study characteristics, methodological quality and outcomes (e.g., infection, other wound complications, pain, and length of hospital stay [LOS]). font-size: 18px; Follow-up ranged from 2 months to 3 years.

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