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aetna breast reduction requirements

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Prepubertal gynecomastia linked to lavender and tea tree oils. 1998;49:215-234. 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). 2006;118(4):840-848. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. Redundant skin was observed in 1 patient at 1 month post-operatively, whose breast, defined as grade-III, was the largest before operation. Among these domains were: vitality, emotional discomfort, limitations due to physical aspects and limitations due to pain. 2013;71(5):471-475. 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. Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. Aesthetic Plast Surg. Plastic Reconstruct Surg. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. # color: white; 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.. Gynaecomastia. OL LI { Plast Reconstr Surg. They concluded that higher resection weight, increased BMI, older age, and smoking are risk factors for complication and that patients should therefore be adequately counseled about losing weight and stopping smoking. This trial included all male patients who presented to the authors breast clinic who were diagnosed with primary gynecomastia, and were treated with a trial of tamoxifen 10 mg daily therapy, over a 10-year period from October 2004 to October 2015. He Q, Zheng L, Zhuang D, et al. 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. Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammaplasty. } .headerBar { J Plast Reconstr Aesthet Surg. Early complications were rare (6.1%), with superficial skin and soft tissue infections accounting for 45.8% of complications. The Mammotome procedure represented another novel therapeutic option for gynecomastia. /*margin-bottom: 43px;*/ OL OL OL OL LI { 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). However, it is unclear if there is any evidence to support this practice. Breast Reduction Surgery and Gynecomastia Surgery - Medical - Aetna Sollie M. Management of gynecomastia-changes in psychological aspects after surgery-a systematic review. Autorino R, Perdona S, D'Armiento M, et al. CG-SURG-71 Reduction Mammaplasty - Anthem #backTop:hover { Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. 2021;147(5):1072-1083. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. OL OL OL LI { In these cases, breast reduction for men may take 2 to 3 hours. } Breast Reduction | American Society of Plastic Surgeons There are alsoseveral earlier, smaller studies that found reductions in symptoms and improvements in quality of life after reduction mammoplasty (Glatt et al, 1999; Bruhlmannand Tschopp, 1998; Blomqvist et al, 2000; and Behmand et al, 2000). Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? Other referencesto smaller studies published prior to the BRAVO study have been cited,examining symptoms before and after reduction mammoplasty; each of these studies suffer from limitations similar to those identified with the BRAVO study. background-color: #cc0066; In total there were 306 women in the 3 trials, and 505 breasts were studied (254 drained, and 251 who were not drained). Last Review01/04/2023. Breast J. Gynecomastia: A systematic review. Most UnitedHealthcare plans have a specific exclusion for breast reduction surgery except as required by the . The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. Devalia HL, Layer GT. Major complications (1.6 %) included unilateral hematoma and localized infection. 2018;24(6):1043-1045. 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: ol.numberedList LI { PDF Breast Reduction Surgery - Commercial Medical Policy - UHCprovider.com border: none; After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. 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 concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. 2014b;30(6):641-647. breast augmentation with implant. The requirement for coverage is that the amount of breast tissue to be removed has to be enough to improve your symptoms or function. PDF Gender Dysphoria Treatment - Cigna Schnur PL, Schnur DP, Petty PM, et al. Gland Surg. 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. 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. 2000;44(2):125-134. Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. Although the BRAVO study is described as a controlled study, the "control" group is obtained, not from the same cohort, but from a separate cohort of individuals recruited from newspaper advertisements and solicitations at meetings for inclusion in a study of the population burden of breast hypertrophy; 75 % of this control group were obtained from2 centers, but the characteristics of those2 centers were not described. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. Gonzalez FG, Walton RL, Shafer B, et al. Qu S, Zhang W, Li S, et al. Many men with breast enlargement are found to have pseudo-gynecomastia. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Fagerlund A, Cormio L, Palangi L, et al. The authorsleave the reader with the conclusionthat decisions about the medical necessity of breast reduction surgery in symptomatic women should be left entirely to the surgeon's discretion. Arlington Heights, IL: ASPRS; 1987. Pseudo-gynecomastia refers to excessive fat tissue or prominent pectoralis muscles. 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. American Society of Plastic Surgeons (ASPS). 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. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. .newText { Measuring health state preferences in women with breast hypertrophy. PDF Summary of Proposed Aetna Medicare Advantage Agreement For many patients the psychological impact of the disease is substantial. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. Three review authors undertook independent screening of the search results. For individuals who received radiation treatment to the chest . Pediatr Surg Int. While the efficacy of radiotherapy as a therapeutic modality for gynecomastia was also established, it was shown to be less effective than other available options. Behmand RA, Tang DH, Smith DJ Jr. Outcomes in breast reduction surgery. Harmonic scalpel versus electrocautery in breast reduction surgery: A randomized controlled trial. Reduction mammaplasty: Defining medical necessity. Krieger LM, Lesavoy MA. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. As explained below, the studies used to support the arguments for the medical necessity of breast reduction surgery are poorly controlled and therefore subject to a substantial risk of bias in the interpretation of results. } Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. Breast pumps. 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 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. Gynecomastia in patients with prostate cancer: Update on treatment options. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. Arlington Heights, IL: ASPS; 2011. In: Townsend CM, Beuchamp RD, Evers BM, eds. Breast. See Appendix for Table 1. The authors (Nguyen et al, 2004) argue, based primarily on the results of the ASPS-funded BRAVO study (described below), that (with a single exception) no objective criteria for breast reduction surgery are supportable, including criteria based upon the presence of particular signs or symptoms, requirements based upon breast size or the amount of breast tissue removed, any minimum age limitations, any limitation based upon maximum body weight, requirements for a trial of conservative therapy, or the exclusion of certain procedures (liposuction). Until now, most published research on the subject has focused on how effective surgical treatment is on correcting the cosmetic appearance of the breast. Ann Plast Surg. Handschin AE, Bietry D, Hsler R, et al. 2008;32(1):38-44. 2008;121(4):1092-1100. 2014a;34(3):409-416. Links to various non-Aetna sites are provided for your convenience only. 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. 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. J Am Coll Surg. These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). 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). Level of Evidence = IV. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. The end-point was the complete resolution of gynecomastia. Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: A review. Abnormalities in Adolescent Breast Development. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. Narula HS, Carlson HE. Khan SM, Smeulders MJ, Van der Horst CM. 2009;7(2):114-119. Refer to the member's specific plan document for applicable coverage. Policy. 01/04/2023 1993;91(7):1270-1276. Treatment of adolescent gynecomastia. These investigators retrospectively examined 83 patients with gynecomastia between January 2015 and December 2019. Breast Reduction Surgery and Gynecomastia Surgery - Medical - Aetna Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. Breast Reduction Surgery | Johns Hopkins Medicine Does Health Insurance Cover Breast Reduction Surgery? - GoodRx Coding } 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. Secondary outcomes included subjective as well as objective assessments of pain and wound healing. Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. Petty PM, Solomon M, Buchel EW, Tran NV. Aesthet Plastic Surg. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. The characteristics of patients as well as the curative effects between the 2 groups were analyzed. Aesthetic Plast Surg. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. Fischer S, Hirsch T, Hirche C, et al. Jones SA, Bain JR. Review of data describing outcomes that are used to assess changes in quality of life after reduction mammaplasty. Recommended criteria for insurance coverage of reduction mammoplasty. Ann Plast Surg. The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 %)]. } The mean age was 42.8 years (SD 19.5 years). Emiroglu M, Salimoglu S, Karaali C, et al. Tobacco use was shown to have a higher rate of reoperation (p= 0.02) and BMI was identified as an independent risk factor for wound complications (odds ratio, 1.85, P = 0.005). 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. Little is known about the effect of surgical treatment on the psychological aspects of the disease. OL OL OL OL OL LI { of . Complications following radiotherapy were minor and self-limiting in all cases, restricted to minor skin reactions, and associated with larger radiotherapy doses delivered in fewer fractions. J Plast Surg Hand Surg. 2015;75(4):383-387. PDF A look at new changes coming to E&M and breast coding in 2021 Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. Plast Reconstr Surg. padding: 10px; 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 81 patients were included in this study. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. All patients underwent routine investigations to exclude secondary causes of gynecomastia. 2012;69(5):510-515. Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. 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. color: red!important; Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. list-style-type: decimal; Kerrigan CL, Collins ED, Kneeland TS, et al. Plast Reconstr Surg. For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. Does Blue Cross Blue Shield Cover Breast Reduction Surgery? - HelpAdvisor 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. Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. 2000;45(6):575-580. 1995;95(1):77-83. Kerrigan CL, Collins ED, Kim HM, et al. } The primary outcome was the difference in wound drainage over 24 hours. Prostate Cancer Prostatic Dis. Burns JL, Blackwell SJ. 2015;75(4):370-375. 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. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. Long-term functional results after reduction mammoplasty. Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. 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). 2015;49(6):363-366. Evidence-based clinical practice guideline: Reduction mammaplasty. 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. However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. Endocrinol Metab Clin North Am. Arlington Heights, IL: ASPS; May 2011. Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). 2 . right: 30px; For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. 1. 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. Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). 2018;7(Suppl 1):S70-S76. This will be computed based on your body area. Please check your insurance policy to see whether breast reduction is a covered procedure. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. Plast Reconstr Surg. 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). Plast Reconstr Surg. @media print { list-style-type: upper-alpha; Gynecomastia is a very common concern of male adolescence. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. PDF Breast Reduction Surgery and Gynecomastia Surgery - Aetna 2021;74(11):3128-3140. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. Horm Res Paediatr. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. Marshall WA, Tanner JM. background: #5e9732; 2019;166(5):934-939. Ann Plastic Surg. In a within-patient, randomized, patient- and assessor-blinded, controlled study, Anzarut et al (2007) evaluated the use of completely autologous platelet gel in 111 patients undergoing bilateral reduction mammoplasty to reduce post-operative wound drainage. Socioeconomic Committee Position Paper. 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). Bland KI, Copeland EM, eds. Am J Infect Control. 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. Breast cancer found at the time of breast reduction. Reduction mammaplasty. 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? The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery.

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