J Plast Surg Hand Surg. Burdette TE, Kerrigan CL, Homa KA. 2006;9(2):109-114. Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. Policy. margin-top: 38px; How to Get Your Breast Reduction Covered By Insurance - RealSelf News 1994;21(3):539-543. 40 . Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance). The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. z-index: 99; These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). The Mammotome procedure represented another novel therapeutic option for gynecomastia. font-size: 18px; Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. 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. Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. Resolution of idiopathic gynecomastia may take several months to years. Ann Chir Plast Esthet. For the first update of this review, these investigators searched the Cochrane Wounds Group Specialised Register (searched March 4, 2015); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 2); Ovid Medline (2012 to March 3, 2015); Ovid Medline (In-Process & Other Non-Indexed Citations March 3, 2015); Ovid Embase(2012 to March 3, 2015); and EBSCO CINAHL (2012 to March 4, 2015). Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. 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. Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammaplasty. American Society of Plastic and Reconstructive Surgery (ASPRS). Handschin AE, Bietry D, Hsler R, et al. 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. cursor: pointer; Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. right: 30px; 2006;30(3):309-319. The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. Howrigan P. Reduction and augmentation mammoplasty. 1999;103(1):76-82; discussion 83-85. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. padding-right: 18px; Harmonic scalpel versus electrocautery in breast reduction surgery: A randomized controlled trial. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. }. } Surgical treatment of gynecomastia: Complications and outcomes. Narula HS, Carlson HE. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Breast reduction outcome study. 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. of the following criteria must be met: Oxford, UK: National Health Service (NHS); October 2008. Plastic surgery for teenagers briefing paper. For medical 2010;45(3):650-654. The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. Burns JL, Blackwell SJ. Reduction mammoplasty or breast reduction surgery reduces the volume and weight of the female breasts by removing excess fat, glandular tissue and skin. Plast Reconstr Surg. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. Arlington Heights, IL: ASPRS; 1987. 1996;20(5):391-397. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. 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. Plast Reconstr Surg. 1997;100(4):875-883. Fagerlund A, Cormio L, Palangi L, et al. PDF Breast Reduction Surgery - Commercial Medical Policy - UHCprovider.com 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). Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, . An 18-question survey was created evaluating various aspects of BBR practice; UK and Irish plastic and reconstructive and breast surgeons were invited to participate by an e-mail containing a link to a web-based survey. However, these medications should be reserved for those with no decrease in breast size after 2 years. Thus, more than 1/3of operative subjects selected for inclusion in the study did not complete it; most of the operative subjects who did not complete the study were lost to follow-up. Mizgala CL, MacKenzie KM. Kasielska-Trojan A, Danilewicz M, Antoszewski B. background-color: #cc0066; Breast Reduction Surgery and Gynecomastia Surgery - Medical - Aetna The authors concluded that the limited evidence available showed no significant benefit of using post-operative wound drains in reduction mammoplasty, although LOS may be shorter when drains are not used. PDF Procedures, programs and drugs you must precertify - AmeriBen and areola. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. 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. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. 2015;49(6):311-318. Plast Reconstr Surg. 2020 Sep 4 [Online ahead of print]. Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. Arch Dis Child. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. 2016;20(3):256-260. 0017 - Breast Reduction Surgery and Gynecomastia Surgery, are met. Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. 2021;74(11):3128-3140. Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. Macromastia: all . 2 . Aetna considers breast reduction surgery medically necessary for non-cosmetic indications for women aged 18 or older or for whom growth is complete (i.e., breast size stable over one year) when any of the following criteria (A, B, or C) is met: Macromastia: all of the following criteria must be met: color:#eee; Several important points should be considered in evaluating these challenges to insurers' criteria for breast reduction surgery. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. Plastic Reconstr Surg. Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. Reduction mammoplasty for asymptomatic members is considered cosmetic. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. Asian J Surg. Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). Fagerlund A, Lewin R, Rufolo G, et al. These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). 2008;121(4):1092-1100. Sugrue CM, McInerney N, Joyce CW, et al. 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. Reduction mammaplasty: A review of managed care medical policy coverage criteria. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS). 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). American Society of Plastic Surgeons (ASPS). Reduction mammoplasty also known as breast reduction surgery, is a surgical procedure in women to reduce the weight, mass, and size of the breast. 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. However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? The nipple-areola complex was re-positioned in 60 % of patients (n = 54). These studies did not find a relationship between breast weight or amount of breast tissue removed and the likelihood of response or magnitude of relief of pain after reduction mammoplasty. Breast reduction surgery - Mayo Clinic Secondary outcomes included subjective as well as objective assessments of pain and wound healing. 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. Breast Reconstructive Surgery - Medical Clinical Policy Bulletins - Aetna Karamanos et al (2015) identified their study as the largest sample on breast reduction in the literature, in which age and surgeon specialty did not correlate with negative results. 2002;33:208-217. Gland Surg. The average amount of breast tissue removed ranged from 430 g per breast to 1.6 kg per breast, with increased body weight associated with an increased amount of breast tissue to be removed. Reduction mammoplasty for macromastia. padding: 10px; American Society of Plastic Surgeons (ASPS). Prostate Cancer Prostatic Dis. 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. 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. Satisfactory chest contour was gained in all cases without any abnormality, skin redundancy, or recurrence during the follow-up of 6 to 48 months. Administration of Benefits and Transition Responsibilities #backTop { Long-term functional results after reduction mammoplasty. Brown MH, Weinberg M, Chong N, et al. 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. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. 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. Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). 2021 Aug 11 [Online ahead of print]. Disproportionately large breasts can cause both physical and emotional . Type II gynecomastia is more generalized breast enlargement. Reduction mammaplasty provides long-term improvement in health status and quality of life. Pediatr Surg Int. J Plast Reconstr Aesthet Surg. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. margin-bottom: 38px; Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. Plast Reconstr Surg. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) ER expression did not correlate with the right (p = 0.51) and left 2D: 4D (p = 0.97). Plastic Reconstruct Surg. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. .strikeThrough { The authors also noted that patients with BMI greater than 40 kg/m were significantly more likely to develop postoperative wound complications (p = 0.02). The investigators found that comorbid conditions increased across obesity classifications (p < 0.001), with significant differences noted in all cohort comparisons except when comparing class I to class II (p = 0.12). Leclere FM, Spies M, Gohritz A, Vogt PM. Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. 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. Prasetyono TOH, Budhipramono AG, Andromeda I, et al. 2009;62(2):195-199. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. This investigators stated that these studies should include data from older individuals affected by gynecomastia and utilize valid tools of psychological measurement in order to better quantify the effect; elderly patients affected by the disease have been over-looked in the current research; more data on this subject could improve the pre-operative evaluation of these patients and help identify the patients who will benefit from treatment. Aetna and the City shall each abide by all applicable laws, regulations and government requirements regarding the confidentiality and the safeguarding of individually identifiable health and other personal information, including the privacy and security requirements of HIPAA. Apart from a significantly shorter LOS for those participants who did not have drains (MD 0.77; 95 % CI: 0.40 to 1.14), there was no statistically significant impact of the use of drains on outcomes. 1998;41(3):240-245. What can I do if my insurance denies coverage for breast reduction? N Engl J Med. 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. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. Aesthetic Plast Surg. 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). top: 0px; padding-bottom: 4px; Data were prospectively gathered on complications as a part of randomized control trial (RCT) examining psycho-socialand quality of life(QOL) benefits of reduction mammoplasty. 2nd ed. Prepubertal gynecomastia linked to lavender and tea tree oils. Reduction mammaplasty. Aetna Coverage Denial - 2nd Appeal (They said I'm overweight) Surgery. 1998;101(2):361-364. CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the You first need to demonstrate that the procedure is "medically necessary and therefore reconstructive rather than cosmetic," says board-certified New York City plastic surgeon Dr. Umbareen Mahmood. Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. Surgical management of gynecomastia--a 10-year analysis. 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.. 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. 2012;130(4):785-789. These preliminary findings need to be validated by well-designed studies. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. He Q, Zheng L, Zhuang D, et al. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). color: red!important; width: 100%; No necrosis, systemic infection, or muscle paralysis was reported. 2013;71(5):471-475. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia. In: Townsend CM, Beuchamp RD, Evers BM, eds. 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). skin should not be excised horizontally below the inframammary fold. Blomqvist L, Eriksson A, Brandberg Y. /* aetna.com standards styles for templates */ } Mental health care professionals may be consulted to address psychological distress from gynecomastia. Sood R, Mount DL, Coleman JJ 3rd, et al. Breast Pump & Breastfeeding Insurance Coverage & Resources | Aetna Fan L, Yang X, Zhang Y, Jiang J. Endoscopic subcutaneous mastectomy for the treatment of gynecomastia: A report of 65 cases. 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. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. 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. PDF Clinical Policy Bulletin: Cosmetic Surgery - Aetna Little is known about the effect of surgical treatment on the psychological aspects of the disease. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. 2008;53(3):255-261. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. Plast Reconstr Surg. Mannu GS, Sudul M, Bettencourt-Silva JH, et al. Breast hypertrophy. Annu Rev Med. OL OL OL OL OL LI { 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%. /*margin-bottom: 43px;*/ Seitchik MW. Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery group. text-decoration: line-through; Am Surg. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. .newText { 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. Clinical Policy: Reduction Mammoplasty and Gynecomastia Surgery - WellCare .newText { li.bullet { Ann Plast Surg. 1. Choban PS, Heckler R, Burge JC, Flancbaum L. Increased incidence of nosocomial infections in obese surgical patients. Patients with abnormal histopathology could not be pre-operatively identified based on demographics. Gynecomastia in patients with prostate cancer: A systematic review. hr.separator { They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. Laituri CA, Garey CL, Ostlie DJ, et al. 1995;95(1):77-83. J Plast Reconstr Aesthet Surg. The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. 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. Often times, insurance company will dictate how much breast tissue to be removed. Plastic Reconstruct Surg. A detailed drug history, including list of medications, an assessment of indirect or environmental exposure to estrogenic compounds, and recreational drug use. This may lead to additional scarring and additional operating time. list-style-type: lower-roman; Level of Evidence = IV. 1993;91(7):1270-1276. 01/04/2023 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. height:2px; # font-weight: bold; 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. Determinants of surgical site infection after breast surgery. 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. This Clinical Policy Bulletin may be updated and therefore is subject to change. To get insurance coverage, you'll probably need . Li CC, Fu JP, Chang SC, et al. Level of Evidence = IV. OL OL OL OL LI { They stated that in the light of these findings, contralateral reduction mammoplasty with histopathological evaluation in breast cancer patients offered a sophisticated tool to catch those patients whose contralateral breast needs increased attention. Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. Setala L, Papp A, Joukainen S, et al. Treating providers are solely responsible for medical advice and treatment of members. There were only 2 studies of a total 25 patients that were considered as good in quality. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate.
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