aetna breast reduction requirements aetna breast reduction requirements

Gland Surg. Blomqvist L, Eriksson A, Brandberg Y. Fan L, Yang X, Zhang Y, Jiang J. Endoscopic subcutaneous mastectomy for the treatment of gynecomastia: A report of 65 cases. 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. 2018;24(6):1043-1045. 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. Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) 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 . Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. Safran T, Abi-Rafeh J, Alabdulkarim A, et al. list-style-type: decimal; of the following criteria must be met: 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. Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. } color: white; Surgical treatment of gynecomastia: Complications and outcomes. 1998;41(3):240-245. Fischer S, Hirsch T, Hirche C, et al. 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. color: red!important; Women's Health and Cancer Rights Act of 1998. } They investigated effects of age on 30-day surgical outcomes for reduction mammoplasty with a goal of improving patient care, counseling, and risk stratification on 3537 patients. The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. Clinical outcomes were measured by operative subjects' responses to a questionnaire about symptoms and quality of life. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. 2014b;30(6):641-647. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. background-color:#eee; It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. 1999;103(6):1687-1690. 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. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. 1998;101(2):361-364. Tang CL, Brown MH, Levine R, et al. Treatment of adolescent gynecomastia. padding: 10px; 1999;103(6):1682-1686. OL OL OL LI { Treating providers are solely responsible for medical advice and treatment of members. (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) Nelson JA, Fischer JP, Chung CU, et al Obesity and early complications following reduction mammaplasty: An analysis of 4545 patients from the 2005-2011 NSQIP datasets. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. Hoyos AE, Perez ME, Dominguez-Millan R, et al. A detailed drug history, including list of medications, an assessment of indirect or environmental exposure to estrogenic compounds, and recreational drug use. background: #5e9732; 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. 2000;45(6):575-580. Links to various non-Aetna sites are provided for your convenience only. 2014a;34(3):409-416. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). } 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. li.bullet { 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. Fischer JP, Cleveland EC, Shang EK, et al. 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). These investigators retrospectively examined 83 patients with gynecomastia between January 2015 and December 2019. The nipple-areola complex was re-positioned in 60 % of patients (n = 54). From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. Ann Plast Surg. J Plast Reconstr Aesthet Surg. 2000;106(2):280-288. Plast Reconstr Surg. Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. 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. 2000;44(2):125-134. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. J Laparoendosc Adv Surg Tech A. Gynecomastia has been classified into2 types. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. Reduction mammoplasty: Criteria for insurance coverage. Determinants of surgical site infection after breast surgery. In the case of breast reduction, however, for insurance purposes, it . Karamanos E, Wei B, Siddiqui A, Rubinfeld I. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). J Plast Surg Hand Surg. 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. Plast Reconstr Surg. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. Asian J Surg. When seeking preauthorization for a breast reduction, your goal is generally twofold. 1993;17(3):211-223. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. The mean age was 42.8 years (SD 19.5 years). list-style-type: lower-roman; However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. 1998;26(1):61-65. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. The Mammotome procedure represented another novel therapeutic option for gynecomastia. A detailed physical examination, including testicular examination. Breast asymmetries: A brief review and our experience. It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. 1991;27(3):232-237. 1. N Engl J Med. Aesthet Plastic Surg. For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. #backTop:hover { Among these domains were: vitality, emotional discomfort, limitations due to physical aspects and limitations due to pain. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. 2015;49(6):363-366. Breast J. 2017;139(6):1313-1322. of . 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. Oxfordshire NHS Trust. To get insurance coverage, you'll probably need . It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. The Breast: Comprehensive Management of Benign and Malignant Diseases. Reduction mammoplasty or breast reduction surgery reduces the volume and weight of the female breasts by removing excess fat, glandular tissue and skin. 01/04/2023 2019;8(4):431-440. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. American Society of Plastic Surgeons (ASPS). Grooving where the bra straps sit on the shoulder. In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. 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). 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. Breast pumps. 2021 Aug 11 [Online ahead of print]. 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. Coding The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. padding: 15px; A non-standardized survey showed a very high satisfaction index. 1997;100(4):875-883. 1990;24(1):61-67. 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. 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. Kinell I, Baeusang-Linder M, Ohlsen L. The effect on the preoperative symptoms and the late results of Skoog's reduction mammoplasty: A follow-up study on 149 patients. 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. 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. Gynecomastia is a very common concern of male adolescence. Am J Infect Control. Washington, DC: ACOG; 2011:121-122. J Pediatr Surg. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. He and associates (2011) examined the safety and feasibility of vacuum-assisted biopsy device in the treatment of gynecomastia. 2005;58(3):286-289. 2009;7(2):114-119. Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. Plast Reconstr Surg. skin should not be excised horizontally below the inframammary fold. list-style-type: upper-alpha; Breast reduction outcome study. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. Annu Rev Med. Gynecomastia may be drug-induced. Plast Reconstr Surg. Flancbaum L, Choban PS. Reduction mammoplasty is among the most commonly performed cosmetic procedures in the United States. } The safety, efficacy, complications, and patient satisfactions were recorded during post-operative follow-up periods. A physician-supervised diet and exercise plan may be indicated in obese patients. 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. 2003;111(2):688-694. 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. 2018;89(6):408-412. 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]). The condition not only must be unresponsive to dermatological treatments (e.g., antibiotics or antifungal therapy) and conservative measures (e.g., good skin hygiene, adequate nutrition) for a period of 6 months or longer, but also must satisfy criteria stated insection I above. Gynaecomastia. Jones SA, Bain JR. Review of data describing outcomes that are used to assess changes in quality of life after reduction mammaplasty. In: Townsend CM, Beuchamp RD, Evers BM, eds. Patient demographics, surgical technique, and outcomes were analyzed. Obesity and complications in breast reduction surgery: Are restrictions justified? The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Aesthet Surg J. } 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. Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). ul.ur li{ Breast reduction for symptomatic macromastia. This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. It's important to note that CPT 19324 - mammaplasty, augmentation without pros-thetic implant - has been deleted. Horm Res Paediatr. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. No necrosis, systemic infection, or muscle paralysis was reported. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. Hoyos and colleagues (2021) stated that male chest definition surgery and patients complaining of breast tissue over-growth have been increasing in recent decades. There were no restrictions on the basis of date or language of publication. These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). The surgeon estimates that at least the following amounts (in grams) of breast tissue, not fatty tissue, will be removed from each breast, based on the member's body surface area (BSA) calculated using theMosteller formula. Ann Plast Surg. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. 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. Plastic Reconstr Surg. J Am Coll 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). 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. 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. And if you are in Canada the surgeon decides. Plastic Reconstruct Surg. Howrigan P. Reduction and augmentation mammoplasty. A total of 90 patients underwent breast re-reduction surgery. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. 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 study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. Priorities Forum Policy Statement. The surgeon must also certify that a certain weight of breast tissue (based on Aetna's table) will be removed in every breast, and not entirely fatty tissue. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. 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. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. margin-top: 38px; Laituri CA, Garey CL, Ostlie DJ, et al. Surgical treatment of primary gynecomastia in children and adolescents. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size.