aetna breast reduction requirements

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. Ann Plast Surg. 2000;45(6):575-580. Ann Chir Plast Esthet. Breast pumps. Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. 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 study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia. A non-standardized survey showed a very high satisfaction index. 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. Arlington Heights, IL: ASPS; March 9, 2002. 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.. 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. Oxfordshire NHS Trust. } Handschin AE, Bietry D, Hsler R, et al. 2014a;34(1):66-73. padding-right: 18px; Wound drainage after plastic and reconstructive surgery of the breast. } Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). See Appendix for Table 1. For additional language assistance: Chemical exfoliation for acne (eg, acne paste, acid), Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy), Diagnostic mammography, including computer-aided detection (CAD) when performed, Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (eg, lip) by activation of photosensitive drug(s), each phototherapy exposure session, Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug(s) provided by a physician or other qualified health care professional, per day, Basic life and/or disability examination that includes: Measurement of height, weight, and blood pressure; Completion of a medical history following a life insurance pro forma; Collection of blood sample and/or urinalysis complying with "chain of custody" protocols; and Completion of necessary documentation/certificates, Weight management classes, non-physician provider, per session, Mononeuropathies of upper limb [upper extremity paresthesia], Gangrene, not elsewhere classified [tissue necrosis], Non-pressure chronic ulcer of skin of other sites, Hypertrophy of breast [symptomatic-causing significant pain, paresthesias, or ulceration], Other specified disorders of breast [soft tissue infection]. 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. Townsend: Sabiston Textbook of Surgery. Analysis was on an intention-to-treat basis. Breast reduction surgery, also known as reduction mammaplasty, removes fat, breast tissue and skin from the breasts. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. Plast Reconstr Surg. color: red!important; A total of 15 articles met the inclusion criteria for review. Radiotherapy was shown to significantly reduce the incidence to a median of 23 %, with all 6 RCTs assessed demonstrating a statistically significant decrease in incidence following radiotherapy prophylaxis. Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). 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. 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. Reduction mammaplasty: Defining medical necessity. 2016;20(3):256-260. Until now, most published research on the subject has focused on how effective surgical treatment is on correcting the cosmetic appearance of the breast. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. J Plast Reconstr Aesthet Surg. 2001;76(5):503-510. 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. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. It's important to note that CPT 19324 - mammaplasty, augmentation without pros-thetic implant - has been deleted. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. The authors recruited 67 consecutive female patients who underwent inferior pedicle reduction mammoplasty in order to determine the effects of resection weight, BMI, age, and smoking on complication rates following reduction mammoplasty. of . width: 100%; 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. display: block; 1996;20(5):391-397. 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. 2006;118(4):840-848. This will be computed based on your body area. Plastic Reconstr Surg. 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). Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. OL OL OL LI { Ann Plast Surg. 2018;89(6):408-412. breast augmentation with implant. 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. The operation was successfully performed in all 20 patients with a mean operating time of 51 mins and a hospital stay of 4 days. 1994;21(3):539-543. 1993;17(3):211-223. Breast asymmetries: A brief review and our experience. Surgeon. 2000;106(5):991-997. 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. of the following criteria must be met: Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. 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. Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. Burns JL, Blackwell SJ. Risk factors for complications following breast reduction: Results from a randomized control trial. Computed tomography scan of adrenal glands to identify adrenal lesions. However, it is unclear if there is any evidence to support this practice. Most UnitedHealthcare plans have a specific exclusion for breast reduction surgery except as required by the . Flancbaum L, Choban PS. /* aetna.com standards styles for templates */ 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. A total of 90 patients underwent breast re-reduction surgery. Reduction mammaplasty. No data were provided on loss to follow-up. Gonzalez FG, Walton RL, Shafer B, et al. Schnur PL, Hoehn JG, Ilstrup DM, et al. color: red 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. 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. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? 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. Prepubertal gynecomastia linked to lavender and tea tree oils. Plast Reconstr Surg. Miller AP, Zacher JB, Berggren RB, et al. list-style-type: lower-roman; background-color: #663399; Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. A study by Glatt et al (1999) was a retrospective analysis of responses to questionnaires sent to patients who underwent reduction mammoplasty regarding physical symptoms and body image. ASPS Recommended Coverage Criteria for Third Party Payors. color:#eee; Asian J Surg. They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. Patient demographics, surgical technique, and outcomes were analyzed. } All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). 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. Liposuction assisted gynecomastia surgery with minimal periareolar incision: A systematic review. Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. Ann Plast Surg. No new trials were identified for this first update. 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%. For individuals who received radiation treatment to the chest . J Pediatr Surg. 2002;33:208-217. Lonie S, Sachs R, Shen A, et al. Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance). Breast. Br J Plast Surg. Policy Statement 6d: Aesthetic surgery procedures. Surgical removal is rarely indicated and the vast majority of the time is for cosmetic reasons, as there is no functional impairment associated with this disorder. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. 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. Med Decis Making. Plast Reconstr Surg. 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. Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. It was also found that only 3 % of subjects reported that they had no aesthetic motivation for surgery. Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery group. 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? Marshall WA, Tanner JM. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. .fixedHeaderWrap { Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. 2019;166(5):934-939. 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. 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. 2007;36(2):497-519. The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. 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. The nipple-areola complex was re-positioned in 60 % of patients (n = 54). Operative subjects who completed the study reported reductions in pain and improvements in quality of life; however, these improvements may be attributable to placebo effects, the natural history of back pain, other concurrent interventions, regression to the mean, improvements in cosmesis (for quality of life measures), or other confounding variables that may bias in interpretation of results. Fagerlund A, Lewin R, Rufolo G, et al. Special Clinical Concerns. Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. 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. The 2 vacuum-assisted breast biopsy systems (Mammotome and Encor) were used for the patients with gynecomastia. These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. 1969;44(235):291-303. li.bullet { Arlington Heights, IL: ASPS; May 2011. Brown DM, Young VL. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. For many patients the psychological impact of the disease is substantial. Grooving where the bra straps sit on the shoulder. } 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. 2007;119(4):1159-1166. Drugs whose mechanism of action is unknown: Others situations which can cause or lead to gynecomastia: The above policy is based on the following references: Last Review Other just require 500 grams no matter what your height and weight. Plastic Reconstr Surg. background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; Type II gynecomastia is more generalized breast enlargement. Well-designed clinical trials provide reliable information about the effectiveness of an intervention, and provide valid information about the characteristics of patients who would benefit from that intervention. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. .arrowPurpleSmall, a:hover.arrowPurpleSmall { Plast Reconstr Surg. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. Plast Reconstr Surg. 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. Nelson et al (2014a) analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. The Mammotome procedure represented another novel therapeutic option for gynecomastia. 1998;49:215-234. Bertin ML, Crowe J, Gordon SM. } Devalia HL, Layer GT. z-index: 99; Please check your insurance policy to see whether breast reduction is a covered procedure. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. Treatment of adolescent gynecomastia. American Society of Plastic and Reconstructive Surgery (ASPRS). Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. Insurers have commonly used the amount of breast tissue to be removed as a criterion for evaluating the medical necessity of breast reduction surgery. A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery. World J Surg. Arlington Heights, IL: ASPS; 2011. However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. Complication rates were inconsistent throughout the studies, ranging from 0.06 % to 26.67 %. Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. 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.

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