aetna breast reduction requirements

This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. Socioeconomic Committee Position Paper. Ann Plast Surg. color: white; Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Resolution of idiopathic gynecomastia may take several months to years. When seeking preauthorization for a breast reduction, your goal is generally twofold. position: fixed; Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. Reduction mammoplasty for macromastia. 2009;62(2):195-199. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Narula HS, Carlson HE. Annu Rev Med. Gynecomastia: Evolving paradigm of management and comparison of techniques. Macromastia: all . 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). 2002;109(5):1556-1566. margin-bottom: 38px; Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. Until now, most published research on the subject has focused on how effective surgical treatment is on correcting the cosmetic appearance of the breast. Gynecomastia surgery is the surgical correction of over-developed or enlarged breasts in men. 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). text-decoration: line-through; 2000;45(6):575-580. Pain/discomfort/ulceration from bra straps cutting into shoulders; Skin breakdown (severe soft tissue infection, tissue necrosis, ulceration hemorrhage) from overlying breast tissue; There is a reasonable likelihood that the member's symptoms are primarily due to macromastia; Reduction mammoplasty (also spelled as 'mammaplasty') is likely to result in improvement of the chronic pain; Pain symptoms persist as documented by the physician despite at least a 3-month trial of therapeutic measures such as: Analgesic/non-steroidal anti-inflammatory drugs (NSAIDs) interventions and/or muscle relaxants, Dermatologic therapy of ulcers, necrosis and refractory infection, Physical therapy/exercises/posturing maneuvers, Supportive devices (e.g., proper bra support, wide bra straps), Chiropractic care or osteopathic manipulative treatment. It's important to note that CPT 19324 - mammaplasty, augmentation without pros-thetic implant - has been deleted. A population-level analysis of bilateral breast reduction: does age affect early complications? 2017;35:157-161. Scand J Plast Reconstr Hand Surg. 1995;34(2):113-116. 1995;61(11):1001-1005. 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. Plast Reconstr Surg. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. 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. The risks included infection, wound breakdown, scarring, and the need for re-operating. The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. 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. Secondary outcomes included subjective as well as objective assessments of pain and wound healing. Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. Level of Evidence = IV. The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. (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. Aetna has their own sliding scale which requires more from smaller patients relative to the Schnur scale, but maxes out at 1000 gms per breast. Oncoplastic reduction mammoplasty for breast cancer in women with macromastia: Oncological long-term outcomes. } Plastic surgery for teenagers briefing paper. li.bullet { The 2 vacuum-assisted breast biopsy systems (Mammotome and Encor) were used for the patients with gynecomastia. 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 . Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. 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. Because reduction mammoplasty may be used for both medically necessary and cosmetic indications, Aetna has set forth above objective criteria to distinguish medically necessary reduction mammoplasty from cosmetic reduction mammoplasty. Three review authors undertook independent screening of the search results. Plast Reconstr Surg. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. No necrosis, systemic infection, or muscle paralysis was reported. 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. Marshall WA, Tanner JM. Vacuum-assisted minimally invasive mastectomy was performed successfully in all cases, with no residual glands or adipose tissue observed on US. The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. 1993;91(7):1270-1276. Administration of Benefits and Transition Responsibilities 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. Kalliainen LK; ASPS Health Policy Committee. 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. Patient demographics, surgical technique, and outcomes were analyzed. Reduction mammoplasty for asymptomatic members is considered cosmetic. Policy Statement 6d: Aesthetic surgery procedures. Grooving where the bra straps sit on the shoulder. CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the ul.ur li{ 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. of . Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. World J Surg. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. 1996;20(5):391-397. A cohort study of breast cancer risk in breast reduction patients. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. Mizgala CL, MacKenzie KM. 2004;113(1):436-437. 2008;53(3):255-261. This conclusion is based primarily upon the Breast Reduction Assessment of Value and Outcomes (BRAVO) study, which is described in several articles (Kerrigan et al, 2001; Kerrigan et al, 2002; Collins et al, 2002). This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. 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. See Appendix for Table 1. } Plastic Reconstruct Surg. There were 18 out of 415 studies eligible to review. For individuals who received radiation treatment to the chest . Schnur PL, Hoehn JG, Ilstrup DM, et al. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. A physician-supervised diet and exercise plan may be indicated in obese patients. Flancbaum L, Choban PS. Fagerlund A, Cormio L, Palangi L, et al. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, . Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). 2021 Aug 11 [Online ahead of print]. Townsend: Sabiston Textbook of Surgery. Br J Plast Surg. He and associates (2011) examined the safety and feasibility of vacuum-assisted biopsy device in the treatment of gynecomastia. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. Breast pumps. 1995;95(1):77-83. In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. Ann Plastic Surg. 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). 2005;58(3):286-289. Clinical outcomes were measured by operative subjects' responses to a questionnaire about symptoms and quality of life. Breast reduction outcome study. Breast J. 1999;103(6):1674-1681. Plast Reconstr Surg. } 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. color: red!important; 2001;108(6):1591-1599. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). 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). Gland Surg. Plast Reconstr Surg. Surgical management of gynecomastia--a 10-year analysis. 2008;32(1):38-44. 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. Autorino R, Perdona S, D'Armiento M, et al. Oxfordshire NHS Trust. However, it is unclear if there is any evidence to support this practice. Other just require 500 grams no matter what your height and weight. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS). 2014b;30(6):641-647. 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. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. A detailed physical examination, including testicular examination. 2006;30(3):309-319. OL OL OL OL LI { Women's Health and Cancer Rights Act of 1998. 2018;89(6):408-412. The authors concluded that small incisional design for breast parenchymal removal in gynecomastia assisted by liposuction showed a good technical approach for consistent improvement in QOL; however, only 2 studies reported good quality methods of non-randomized case-series urging for a better quality of studies in the future. 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). Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. 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. 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. For medical Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. 2003;111(2):688-694. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. 2018;7(Suppl 1):S70-S76. The primary outcome was the difference in wound drainage over 24 hours. Plastic Reconstr Surg. Gonzalez FG, Walton RL, Shafer B, et al. .strikeThrough { From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. In other patients, excess skin and nipple and areola relocation are necessary. Breast reduction surgery is considered cosmetic for all indications not listed in section I, A. Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). Sugrue and associates (2015) evaluated the current practice patterns of drains usage by plastic and reconstructive and breast surgeons in United kingdom (UK) and Ireland performing bilateral breast reduction (BBR). background: #5e9732; } outline: none; Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. Often times, insurance company will dictate how much breast tissue to be removed. 2015;49(6):363-366. 2001;76(5):503-510. There were no restrictions on the basis of date or language of publication. Gynecomastia is a very common concern of male adolescence. background-color:#eee; padding: 10px; 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. 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]). However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. Reduction mammoplasty or breast reduction surgery reduces the volume and weight of the female breasts by removing excess fat, glandular tissue and skin. A total of 81 patients were included in this study. Sugrue CM, McInerney N, Joyce CW, et al. Srinivasaiahet al (2014) stated that although reduction mammoplasty has been shown to benefit physical, physiological, and psycho-social health there are recognized complications. .fixedHeaderWrap { Statistical analysis was performed with student t-test and chi-square test. 1993;17(3):211-223. Anesthesia may be injected along with saline solution until the tissue is firm, and a suction cannula is used to extract fat from the breast. The average amount of tissue removed from an average weight woman (within the 70 to 74.9 kg weight band) in this study was 600 g per breast, with a range of 502 g to 700 g of tissue removed per breast. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. Reduction mammoplasty improves symptoms of macromastia. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; border-radius: 4px; Plast Reconstr Surg. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. Kerrigan CL, Collins ED, Kim HM, et al. The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. Mayo Clin Proc. Plast Reconstr Surg. Fischer JP, Cleveland EC, Shang EK, et al. Principles of breast re-reduction: A reappraisal. border: none; Pediatr Surg Int. } 1969;44(235):291-303. And if you are in Canada the surgeon decides. Reduction mammoplasty: Criteria for insurance coverage. right: 30px; Plastic Reconstruct Surg. These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). No other operation-related complications were observed. J Plast Surg Hand Surg. list-style-type: upper-alpha; 2 . They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. A total of 3 RCTs were identified and included in the review out of 190 studies that were initially screened; all evaluated wound drainage after breast reduction surgery. Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain. 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. 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. Fagerlund A, Lewin R, Rufolo G, et al. background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; 2016;20(3):256-260. 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. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. 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.. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. Plast Reconstr Surg. Ann Plast Surg. Tang CL, Brown MH, Levine R, et al. 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. padding-bottom: 4px; J Laparoendosc Adv Surg Tech A. 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. Gynecomastia has been classified into2 types. 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. 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. /* aetna.com standards styles for templates */ Plast Reconstr Surg. Collis N, McGuiness CM, Batchelor AG. Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. Fischer et al (2014a) evaluated predictors of postoperative complications following reduction mammoplasty using the NSQIP) data sets. Breast hypertrophy. J Plast Reconstr Aesthet Surg. However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. The American Society for Plastic Surgery (2011) advises to delay surgery until breast growth ceases: Although waiting may prolong the psychological awkwardness, it is advisable to delay surgery until breast growth ceases in order to achieve the best result. This is similar tothe American College of Obstetricians and Gynaecologists'2011 Guidelines forAdolescent Health Care chapter on breast concerns in adolescents, which states regarding breast hypertrophy: Preferably, treatment should be deferred until breast growth has been completed. Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. J Pediatr Surg. Management of gynecomastia should include evaluation, including laboratory testing, to identify underlying etiologies. For these reasons, there is insufficient evidence to support the use of reduction mammoplasty, without regard to the size of the breasts or amount of breast tissue to be removed, as a method of relieving chronic back, neck, or shoulder pain. 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. 2012;130(4):785-789. cursor: pointer; 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. 2017;139(6):1313-1322. Yao Y, Yang Y, Liu J, et al. /*margin-bottom: 43px;*/ Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. .headerBar { } Breast reduction surgery might also help improve self-image and the ability to take part in physical activities. Reduction mammaplasty: The need for prospective randomized studies. OL LI { OL OL LI { Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. Insurers have commonly used the amount of breast tissue to be removed as a criterion for evaluating the medical necessity of breast reduction surgery. 2006;118(4):840-848. This population-wide analysis - the largest and most heterogeneous study to date - has demonstrated that increasing obesity class is associated with increased early postoperative complications. 18th ed. } 2019;8(4):431-440. background-color: #663399; Aesthetic Plast Surg. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. 2009;7(2):114-119. Ann Chir Plast Esthet. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. This will be computed based on your body area. Asian J Surg. Arlington Heights, IL: ASPRS; 1987. 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. Gynaecomastia. High-risk lesions (atypical ductal hyperplasia [ADH], atypical lobular hyperplasia [ALH], and lobular carcinoma in situ [LCIS]) were revealed in 37 (11.7 %), and cancer in 6 (1.9 %) patients. list-style-type : square !important; Burdette TE, Kerrigan CL, Homa KA. Choban PS, Heckler R, Burge JC, Flancbaum L. Increased incidence of nosocomial infections in obese surgical patients. 2019;166(5):934-939. Chadbourne EB, Zhang S, Gordon MJ, et al. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. Risk factors for complications following breast reduction: Results from a randomized control trial. background-position: right 65%; Saunders Co.; 1991. Plast Reconstr Surg. Am J Infect Control. Early complications were rare (6.1%), with superficial skin and soft tissue infections accounting for 45.8% of complications. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? American Society of Plastic and Reconstructive Surgery (ASPRS). 1995;95(6):1029-1032. The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. 2014;20(3):274-278. 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). color: red The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011.