aetna breast reduction requirements

J Plast Reconstr Aesthet Surg. Level of Evidence = III. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. A physician-supervised diet and exercise plan may be indicated in obese patients. Devalia HL, Layer GT. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. Glatt BS, Sarwer DB, O'Hara DE, et al. 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. Aetna's Itty Bitty Titty Committee - by Libby Watson - Sick Note Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. font-size: 18px; Karamanos E, Wei B, Siddiqui A, Rubinfeld I. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. How to make Aetna pay for your breast reduction surgery 2015;75(4):370-375. 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. 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. .fixedHeaderWrap { Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Plast Reconstr Surg. CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery group. They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. Arlington Heights, IL: ASPS; 2011. Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. color: #FFF; Breast asymmetries: A brief review and our experience. This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. 2 . This may lead to additional scarring and additional operating time. Please check your insurance policy to see whether breast reduction is a covered procedure. of . Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. PDF Clinical Policy Bulletin: Cosmetic Surgery - Aetna All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). margin-bottom: 38px; 2013;71(5):471-475. Breast pumps. # font-weight: bold; Plast Reconstr Surg. 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. 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. A total of 81 patients were included in this study. #backTop:hover { 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. The risks included infection, wound breakdown, scarring, and the need for re-operating. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. 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. Furthermore, you must test negative for breast cancer on a mammogram a maximum of two years before your surgery if you are 50 or older. Breast and aesthetic 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 2006;9(2):109-114. 2010;125(5):1301-1308. These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. It is not intuitively obvious, however, that breast weight would substantially contribute to back, neck and shoulder pain in women with normal or small breasts. First, the opinions and guidelines of medical professional organizations and consensus groups are considered according to the quality of the scientific evidence and supporting rationale. Arlington Heights, IL: ASPS; March 9, 2002. 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. 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). 2000;106(2):280-288. Healing balms, scented soaps, skin lotions, shampoos and styling gels containing lavender oilor tea tree oil. 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. Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. Policy. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. 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. 2005;58(3):286-289. Plast Reconstr Surg. Many men with breast enlargement are found to have pseudo-gynecomastia. Prasetyono TOH, Budhipramono AG, Andromeda I, 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. 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). ER expression did not correlate with the right (p = 0.51) and left 2D: 4D (p = 0.97). If breast growth has been completed, breast reduction surgery is an option. Marshall and Tanner (1969)shows that the final stage of breast maturityoccurs about age 15 on average, but there is wide variation. 2015;75(4):383-387. Grooving where the bra straps sit on the shoulder. Breast Reduction Surgery | Johns Hopkins Medicine OL LI { 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. A follow-up study of 105 women with breast cancer following reduction mammaplasty. Breast Reduction | American Society of Plastic Surgeons American Society of Plastic Surgeons (ASPS). Orthopedic or spine surgeon evaluation of spinal pain; Radiotherapy (for the prevention or management of gynecomastia recurrence); Vacuum-assisted breast biopsy system for treament of gynecomastia. Plast Reconstr Surg. Major complications (1.6 %) included unilateral hematoma and localized infection. 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. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. Surg Laparosc Endosc Percutan Tech. Gonzalez FG, Walton RL, Shafer B, et al. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. Mayo Clin Proc. and areola. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Patients with abnormal histopathology could not be pre-operatively identified based on demographics. When seeking preauthorization for a breast reduction, your goal is generally twofold. Plast Reconstr Surg. PDF Clinical Policy Bulletin: BRCA Testing, Prophylactic Mastectomy - Aetna Long-term functional results after reduction mammoplasty. Measuring health state preferences in women with breast hypertrophy. Autorino R, Perdona S, D'Armiento M, et al. } border-radius: 4px; Risk factors for complications following breast reduction: Results from a randomized control trial. Krieger LM, Lesavoy MA. 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). 2008;53(3):255-261. 01/04/2023 A study reporting on a survey of health insurer policies on breast reduction surgery (Nguyen et al, 2004) found that no insurer medical policies could be supported by the medical literature. Note: Chronic intertrigo, eczema, dermatitis, and/or ulceration in the infra-mammary fold in and of themselves are not considered medically necessary indications for reduction mammoplasty. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). Reduction mammoplasty improves symptoms of macromastia. hr.separator { Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. padding-bottom: 4px; 1991;27(3):232-237. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. A non-standardized survey showed a very high satisfaction index. Tobacco use was shown to have a higher rate of reoperation (p= 0.02) and BMI was identified as an independent risk factor for wound complications (odds ratio, 1.85, P = 0.005). padding: 10px; Breast J. } In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. Evidence-based clinical practice guideline: Reduction mammaplasty. Level of Evidence = IV. The Mammotome procedure represented another novel therapeutic option for gynecomastia. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. Breast Reduction Surgery and Gynecomastia Surgery - Medical - Aetna The safety, efficacy, complications, and patient satisfactions were recorded during post-operative follow-up periods. Breast Concerns of Adolescents. 1997;185(6):593-603. Burdette TE, Kerrigan CL, Homa KA. J Plast Surg Hand Surg. PDF 0185 Breast Reconstructive Surgery (1) - Aetna In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. Brown DM, Young VL. 2016;20(3):256-260. Breast J. Current concepts in gynaecomastia. Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. Kalliainen LK; ASPS Health Policy Committee. 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. 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). The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. Plast Reconstr Surg. 2010;45(3):650-654. Scand J Plast Reconstr Hand Surg. Schnur et al (1991) reported on a sliding scale assigns a weight of breast tissue to be removed based on body weight and surface area. With approval from the authors institutional ethics committee and written informed consent, a total of 22 patients with 33 abnormally hyperplastic breasts were enrolled at the First Affiliated Hospital with Nanjing Medical University between June 2016 and September 2018. Tang CL, Brown MH, Levine R, et al. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. Plast Reconstr Surg. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . Reduction mammoplasty: Cosmetic or reconstructive procedure? The median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. All RCTs that compared the use of a wound drain with no wound drain following plastic and reconstructive surgery of the breast (breast augmentation, breast reduction and breast reconstruction) in women were eligible. Can objective predictors for operative success be identified? Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. In a liposuction-only reduction mammoplasty, a small access incision is made in one of the following locations: axillary (under the arm), periareolar (around the nipple) or in the inframammary fold (under the breast). In a survey of managed care policies regarding breast reduction surgery, Krieger and colleagues reported (2001)found that mostof the respondentsstated that they use weight of excised tissue as the main criterion for allowing the procedure, with anaverage cut-off value of 472 grams for a typicalwoman. Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). 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). li.bullet { 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. Pediatr Surg Int. 2017;35:157-161. 1969;44(235):291-303. ASPS Recommended Coverage Criteria for Third Party Payors. Does Blue Cross Blue Shield Cover Breast Reduction Surgery? - HelpAdvisor Fischer S, Hirsch T, Hirche C, et al. Srinivasaiah N, Iwuchukwu OC, Stanley PR, et al. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. .strikeThrough { Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. To get insurance coverage, you'll probably need . 2014a;34(1):66-73. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. Leclere FM, Spies M, Gohritz A, Vogt PM. 2000;44(2):125-134. Plast Reconstr Surg. The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. #closethis { 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. Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). 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. The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. 2006;30(3):309-319. Breast reduction surgery (also called reduction mammaplasty) is a type of invasive procedure that involves incisions (cuts) in your skin to decrease the size and weight of your breasts . Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, . What are Aetna breast reduction requirements? - RealSelf.com Priorities Forum Policy Statement. Gynecomastia: A systematic review. Ann Plastic Surg. Three review authors undertook independent screening of the search results. Collis N, McGuiness CM, Batchelor AG. Fagerlund A, Cormio L, Palangi L, et al. Sixteen (23%) patients had complications and higher resection weight, increased BMI, and older age were found to have statistically significant complication rates with p-values of p<0.001, p=0.034, and p=0.004, respectively.The investigators also found that the incidence of complications was highest among current smokers and lowest among those who had never smoked with a 37% difference in the occurrence of complication (p<0.01). } Sood R, Mount DL, Coleman JJ 3rd, et al. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. 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. 2001;107(5):1234-1240. 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. J Plast Reconstr Aesthet Surg. Obstet Gynecol Clin North Am. Based largely upon these results, Nguyen et al (2004) reached the conclusion that a trial of conservative management is not an appropriate criterion for insurance coverage, even though responses to the BRAVO questionnaire indicated that operative candidates and hypertrophy controls received at least some pain relief from all of the conservative interventions, and for some conservative interventions, virtually all subjects reported at least some pain relief. No data were provided on loss to follow-up. 18th ed. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. background-position: right 65%; .strikeThrough { 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. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. Reduction mammoplasty performed solely for cosmetic indications is considered by insurers to be not medically necessary treatment of disease and subject to the standard cosmetic surgery plan exclusion. 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. This will be computed based on your body area. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. Statistical analysis was performed with student t-test and chi-square test. World J Surg. Plast Reconstr Surg. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. A population-level analysis of bilateral breast reduction: does age affect early complications? of the following criteria must be met: Administration of Benefits and Transition Responsibilities Plast Reconstr Surg. 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. 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). Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? A total of 244 out of 1,628 patients with the average age of 23.13 years. 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. Coding They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. } Ann Plast Surg. Horm Res Paediatr. 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. background: #5e9732; 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. Prostate Cancer Prostatic Dis. 1998;101(2):361-364. Does Health Insurance Cover Breast Reduction Surgery? - GoodRx list-style-type: decimal; 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). Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. Second, it is the burden of the proponent of an intervention to provide reliable evidence of its effectiveness, not the burden of ones whoquestion the effectivenessan intervention to provide definitive proof of ineffectiveness. The study subjects were stratified into groups based on ages of <60 years and 60 years. 2000;45(6):575-580. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. Fourth, insurers have provided coverage for reduction mammoplasty in women with excessively large breasts; thus, the debate is about the effectiveness of removal of smaller amounts of breast tissue from women whose breast size most persons would consider within the normal range. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. cursor: pointer; 2017;139(6):1313-1322. 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).

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