aetna breast reduction requirements

Three review authors undertook independent screening of the search results. 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. 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. Recommended criteria for insurance coverage of reduction mammoplasty. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. Policy. Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. margin-bottom: 38px; Gonzalez FG, Walton RL, Shafer B, et al. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. Grooving where the bra straps sit on the shoulder. The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. of the following criteria must be met: Patients with abnormal histopathology could not be pre-operatively identified based on demographics. Ann Plast Surg. Breast reduction surgery, also known as reduction mammaplasty, removes fat, breast tissue and skin from the breasts. The mean volume of tissue resected was 250 g (range of 22 to 758 g) from the right breast and 244 g (range of 15 to 705 g) from the left breast. Gynecomastia: A systematic review. How to make Aetna pay for your breast reduction surgery 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). The investigators reported that subjects who were of normal weight were as likely to report benefit from reduction mammoplasty as subjects who were over-weight. The authors concluded that gynecomastia treatment combining high-definition liposculpture to male breast tissue resection via a new, almost invisible incision allowed these researchers to achieve an athletic and natural appearance of the male pectoral area with a very low rate of complications. A total of 2779 patients were identified with a mean age of 42.7 (14.1) years and BMI of 31.6 (7.0) kg/m. N Engl J Med. 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%. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. skin should not be excised horizontally below the inframammary fold. 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". 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. Does Blue Cross Blue Shield Cover Breast Reduction Surgery? - HelpAdvisor However, it is unclear if there is any evidence to support this practice. In total there were 306 women in the 3 trials, and 505 breasts were studied (254 drained, and 251 who were not drained). OL OL OL LI { Burns JL, Blackwell SJ. Plastic Reconstr Surg. Abnormalities in Adolescent Breast Development. The authors of the BRAVO study reached several conclusions about reduction mammoplasty, most notably that breast size or the amount of breast tissue removed does not have any relationship to the outcome of breast reduction surgery (Kerrigan et al, 2002; Collins et al, 2002). 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. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. Scand J Plast Reconstr Hand Surg. 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? 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. Li CC, Fu JP, Chang SC, et al. text-decoration: line-through; Setala L, Papp A, Joukainen S, et al. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. 01/04/2023 Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. Plast Reconstr Surg. Behmand RA, Tang DH, Smith DJ Jr. Outcomes in breast reduction surgery. 2000;106(5):991-997. Plastic Reconstr Surg. Often, you'll be eligible for Blue Cross Blue Shield breast reduction coverage if your surgeon plans to remove at least 500 grams of breast tissue per breast. Arlington Heights, IL: ASPS; May 2011. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. Qu and colleagues (2020) examined the effectiveness of vacuum-assisted breast biopsy systems for the treatment of gynecomastia. 18th ed. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). 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. 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). Surgical implications of obesity. Other referencesto smaller studies published prior to the BRAVO study have been cited,examining symptoms before and after reduction mammoplasty; each of these studies suffer from limitations similar to those identified with the BRAVO study. Bertin ML, Crowe J, Gordon SM. Behmand et al (2000) reported on the results of a questionnaire pre- and post-surgery in 69 subjects from a single practice who underwent reduction mammoplasty. color: #FFF; They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. cursor: pointer; A follow-up study of 105 women with breast cancer following reduction mammaplasty. To get insurance coverage, you'll probably need . Mannu GS, Sudul M, Bettencourt-Silva JH, et al. Laituri CA, Garey CL, Ostlie DJ, et al. Qu S, Zhang W, Li S, et al. 2014b;30(6):641-647. Can objective predictors for operative success be identified? OL LI { Level of Evidence = IV. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. 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. 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]). Ann Plast Surg. Breast Reduction Surgery: Procedure, Recovery, Cost, and More - Healthline The author concluded that the current level of evidence on this subject was very low and future studies, examining the impact of the surgical intervention for gynecomastia on psychological domains, are greatly needed. Breast and aesthetic surgery. These investigators retrospectively examined 83 patients with gynecomastia between January 2015 and December 2019. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). hr.separator { 2012;69(5):510-515. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. Asian J Surg. 1997;100(4):875-883. Priorities Forum Policy Statement. background: #5e9732; #closethis { The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. Gland Surg. 1999;103(6):1674-1681. } Gynecomastia in patients with prostate cancer: Update on treatment options. Level of Evidence = IV. Moreover, these researchers stated that further studies are needed within the common gynecomastia population managed by plastic surgeons to examine the clinical and economical utility of this intervention before a recommendation for its ubiquitous adoption in plastic surgery can be made to continue improving outcomes for high-risk gynecomastia patients. 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. right: 30px; Coding Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. /*margin-bottom: 43px;*/ 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. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. 1995;34(2):113-116. color: blue Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery group. Refer to the member's specific plan document for applicable coverage. Fischer JP, Cleveland EC, Shang EK, et al. 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. Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. top: 0px; Last Review01/04/2023. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Breast Reduction Surgery and Gynecomastia Surgery - Medical - Aetna Oncoplastic reduction mammoplasty for breast cancer in women with macromastia: Oncological long-term outcomes. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. PDF Procedures, programs and drugs you must precertify - AmeriBen The end-point was the complete resolution of gynecomastia. cursor: pointer; Blomqvist L, Eriksson A, Brandberg Y. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. Hoyos AE, Perez ME, Dominguez-Millan R, et al. The authors concluded that this study was the largest to-date examining the role of tamoxifen in idiopathic gynecomastia, and these findings showed approximately 9 in every 10 men treated with tamoxifen therapy had successful resolution of their symptoms. The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 %)]. Evidence-based clinical practice guideline: Reduction mammaplasty. 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. This Clinical Policy Bulletin may be updated and therefore is subject to change. Although the BRAVO study is described as a controlled study, the "control" group is obtained, not from the same cohort, but from a separate cohort of individuals recruited from newspaper advertisements and solicitations at meetings for inclusion in a study of the population burden of breast hypertrophy; 75 % of this control group were obtained from2 centers, but the characteristics of those2 centers were not described. Philadelphia, PA: W.B. Only 8 (9.9 %) patients did not have a complete resolution following tamoxifen therapy, of which 2 underwent subsequent surgical resection of their symptomatic gynecomastia. Each surgeon who participated in the study reported on the height, weight, and volume of reduction of their last 15 to 20 patients, and each surgeon provided their intuitive sense regarding the motivation of each patient for breast reduction surgery. Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance). J Pediatr Surg. CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the Fagerlund A, Cormio L, Palangi L, et al. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. # color: white; 1998;41(3):240-245. breast augmentation with implant. PLoS One. Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. All the patients recovered well and were satisfied with the cosmetic outcomes. Breast Reduction Surgery and Gynecomastia Surgery - Medical - Aetna Mistry RM, MacLennan SE, Hall-Findlay EJ. li.bullet { 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: white; The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. 2003;111(2):688-694. In the case of breast reduction, however, for insurance purposes, it . Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). Breast Reduction | American Society of Plastic Surgeons 2016;20(3):256-260. For individuals who received radiation treatment to the chest . The investigators found that comorbid conditions increased across obesity classifications (p < 0.001), with significant differences noted in all cohort comparisons except when comparing class I to class II (p = 0.12). Long-term functional results after reduction mammoplasty. 2015;49(6):363-366. 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: 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., breastsize stable over one year) when any of the following criteria (A, B, or C) is met: Member has persistent symptoms in at leasttwoof the anatomical body areas below, directly attributed to macromastia and affecting daily activities for at least1 year: Member has severe breast hypertrophy, documented by high-quality color frontal-view and side-view photographs;and, Women50 years of age or older are required to have a mammogram that was negative for cancer performed within the twoyears prior to the date of the planned reduction mammoplasty;and. The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. Insurers have commonly used the amount of breast tissue to be removed as a criterion for evaluating the medical necessity of breast reduction surgery. 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. Ann Chir Plast Esthet. Type II gynecomastia is more generalized breast enlargement. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. Aesthetic Plast Surg. 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). 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). background-color:#eee; 2006;30(3):309-319. This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. Surgeon. 2010;125(5):1301-1308. z-index: 99; 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). Hoyos and colleagues (2021) stated that male chest definition surgery and patients complaining of breast tissue over-growth have been increasing in recent decades. Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammaplasty. background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; The Breast: Comprehensive Management of Benign and Malignant Diseases. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. Liposuction assisted gynecomastia surgery with minimal periareolar incision: A systematic review. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. Often times, insurance company will dictate how much breast tissue to be removed. Links to various non-Aetna sites are provided for your convenience only. Reduction mammoplasty for asymptomatic members is considered cosmetic. My Experience of Having Breast Reduction Surgery - Health 1. 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). In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. Jones SA, Bain JR. Review of data describing outcomes that are used to assess changes in quality of life after reduction mammaplasty. There were 18 out of 415 studies eligible to review. 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. Management of gestational gigantomastia. Washington, DC: ACOG; 2011:121-122. There were no restrictions on the basis of date or language of publication. 2015;10(8):e0136094. Breast Reduction Surgery | Johns Hopkins Medicine .arrowPurpleSmall, a:hover.arrowPurpleSmall { 2014a;34(3):409-416. } Reduction mammaplasty: The need for prospective randomized studies. } No necrosis, systemic infection, or muscle paralysis was reported. 2001;108(6):1591-1599. Breast J. This investigators stated that these studies should include data from older individuals affected by gynecomastia and utilize valid tools of psychological measurement in order to better quantify the effect; elderly patients affected by the disease have been over-looked in the current research; more data on this subject could improve the pre-operative evaluation of these patients and help identify the patients who will benefit from treatment. 2008;61(5):493-502. 2007;36(2):497-519. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. 1995;95(6):1029-1032. 2014b;48(5):334-339. PDF 0185 Breast Reconstructive Surgery (1) - Aetna Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, . American Society of Plastic Surgeons (ASPS). Plast Reconstr Surg. Risk of bias was assessed independently by 2review authors. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. J Plast Reconstr Aesthet Surg. Inclusion criteria were as follows: men diagnosed with gynecomastia and BMI of less than or equal to 32 kg/m2, adequate skin elasticity, and general good health. 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.