In total there were 306 women in the 3 trials, and 505 breasts were studied (254 drained, and 251 who were not drained). 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. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. A follow-up study of 105 women with breast cancer following reduction mammaplasty. Analysis was on an intention-to-treat basis. Gynecomastia is a very common concern of male adolescence. 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. Breast asymmetries: A brief review and our experience. Surgery. Fischer et al (2014a) evaluated predictors of postoperative complications following reduction mammoplasty using the NSQIP) data sets. 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. J Plast Reconstr Aesthet Surg. } 1994;21(3):539-543. Plast Reconstr Surg. text-decoration: underline; Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. Prasetyono TOH, Budhipramono AG, Andromeda I, et al. } 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. Mannu GS, Sudul M, Bettencourt-Silva JH, et al. The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. No new trials were identified for this first update. Hello! 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. list-style-type: upper-alpha; Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . A detailed drug history, including list of medications, an assessment of indirect or environmental exposure to estrogenic compounds, and recreational drug use. Marshall WA, Tanner JM. Chadbourne EB, Zhang S, Gordon MJ, et al. Aetna considers magnetic resonance imaging (MRI), with or without contrast materials, of the breast medically necessary for members who have had a recent (within the past year) conventional mammogram and/or breast sonogram, in any of the following circumstances where MRI of the breast may affect their clinical management:. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. The Mammotome procedure represented another novel therapeutic option for gynecomastia. 2002;33:208-217. 2015;49(6):363-366. ul.ur li{ Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). Recommended criteria for insurance coverage of reduction mammoplasty. 0017 - Breast Reduction Surgery and Gynecomastia Surgery, are met. The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. Aetna considers breast reconstructive surgery to correct Reduction mammaplasty. } position: fixed; Plast Reconstr Surg. Prostate Cancer Prostatic Dis. Aetna considers breast reconstructive surgery to correct breast asymmetry cosmetic except for the following conditions: Surgical correction of chest wall deformity causing functional deficit in Poland syndrome when criteria are met in CPB 0272 - Pectus Excavatum and Poland's Syndrome: Surgical Correction; or Subjects were compared to age-matched norms from another study cohort. Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia. Drugs commonly associated with the development of gynecomastia include amphetamines, marijuana, mebrobamate, opiates, amitriptyline, chlordiazepoxide, chlorpromazine, cimetidine, diazepam, digoxin, fluphenazine, haloperidol, imipramine, isoniazid, mesoridazine, methyldopa, perphenazine, phenothiazines, reserpine, spironolactone, thiethylperazine, tricyclic antidepressants, tirfluoperazine, trimeparazine, busulfan, vincristine, tamoxifen, , methyltestosterone, human chorionic gonadotropins, and estrogens. Also, there was no correlation between PR expression and 2D: 4D. Surgical treatment of primary gynecomastia in children and adolescents. 2 . Handschin AE, Bietry D, Hsler R, et al. Risk of bias was assessed independently by 2review authors. Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. 2011;128(4):243e-249e. What are Aetna breast reduction requirements? - RealSelf.com The following procedures are considered experimental and investigational because there is insufficient evidence of itseffectiveness or itseffectiveness has not been established: Aetna considers breast reduction, surgical mastectomy or liposuction for gynecomastia, either unilateral or bilateral, a cosmetic surgical procedure. Plast Reconstr Surg. J Pediatr Surg. These investigators retrospectively examined 83 patients with gynecomastia between January 2015 and December 2019. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. World J Surg. 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). See Appendix for Table 1. } J Plast Surg Hand Surg. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. Reduction mammoplasty improves symptoms of macromastia. OL OL OL OL OL LI { Macromastia: all . Plastic Reconstruct Surg. The authors specified the value of these study results was in the identification of morbid obesity as a significant predictor of overall morbidity and active smoking as a strong predictor of major surgical morbidity. Breast reduction for symptomatic macromastia. For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. The authors reach the remarkable conclusion that a woman with normal sized breasts who has only a few ounces of breast tissue removed is as likely to receive as much benefit from breast reduction surgery as a women with large breasts who has substantially more breast tissue removed. 2007;356(5):479-485. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. breast augmentation with implant. How to make Aetna pay for your breast reduction surgery Breast Reduction Surgery and Gynecomastia Surgery - Medical - Aetna Current concepts in gynaecomastia. Arlington Heights, IL: ASPRS; 1987. 2000;106(2):280-288. }. Plast Reconstr Surg. The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. Srinivasaiahet al (2014) stated that although reduction mammoplasty has been shown to benefit physical, physiological, and psycho-social health there are recognized complications. 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. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). 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.. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. Townsend: Sabiston Textbook of Surgery. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. 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. The investigators found little difference between obese and non-obese women concerning patient's reports of resolution of symptoms and improvement in body image. color: #FFF; 1991;27(3):232-237. Several important points should be considered in evaluating these challenges to insurers' criteria for breast reduction surgery. And if you are in Canada the surgeon decides. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. Early complications were rare (6.1%), with superficial skin and soft tissue infections accounting for 45.8% of complications. Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, . 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. A total of 90 patients underwent breast re-reduction surgery. } Surgical treatment is indicated when medical treatments fail. Photographs were taken pre-operatively and 1, 3, 6, and 12 months post-operatively. Reduction mammaplasty: Defining medical necessity. The operation was successfully performed in all 20 patients with a mean operating time of 51 mins and a hospital stay of 4 days. 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. 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. 2nd ed. Aesthetic Plast Surg. Gynecomastia surgery is the surgical correction of over-developed or enlarged breasts in men. Gland Surg. Washington, DC: ACOG; 2011:121-122. CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the PDF Breast Reduction Surgery - Commercial Medical Policy - UHCprovider.com 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. The median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. Surgical treatment of gynecomastia: Complications and outcomes. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. Breast pumps. 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. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. margin-top: 38px; 2013;71(5):471-475. ASPS Recommended Coverage Criteria for Third Party Payors. Breast reduction surgery (also called reduction mammaplasty) is a type of invasive procedure that involves incisions (cuts) in your skin to decrease the size and weight of your breasts . Breast. Priorities Forum Policy Statement. list-style-type : square !important; 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]. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). Special Clinical Concerns. Mental health care professionals may be consulted to address psychological distress from gynecomastia. Khan SM, Smeulders MJ, Van der Horst CM. A detailed physical examination, including testicular examination. Statistical analysis was performed with student t-test and chi-square test. 2018;24(6):1043-1045. 2002;109(5):1556-1566. Br J Plast Surg. Last Review01/04/2023. Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. Plast Reconstr Surg. Ages ranged from 18 to 66 years. ol.numberedList LI { GP Notebook. Plast Reconstr Surg. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. 2010;125(5):1301-1308. Horm Res Paediatr. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. PDF Summary of Proposed Aetna Medicare Advantage Agreement Reduction mammoplasty: Criteria for insurance coverage. A total of 15 articles met the inclusion criteria for review. 2005;55(3):227-231. cursor: pointer; Nguyen JT, Wheatley MJ, Schnur PL, et al. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. 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. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. Several of the included studies reported improvement in QOL and several psychological domains after surgical treatment for gynecomastia. Measuring health state preferences in women with breast hypertrophy. Collins ED, Kerrigan CL, Kim M, et al. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. Within this study population, 54.4% of patients were obese (BMI > 30 kg/m2), of which 1308 (28.8%) were Class I (BMI = 30-34.9 kg/m2), 686 (15.1%) were Class II (BMI = 35-39.9 kg/m2), and 439 (9.7%) were Class III (BMI > 40 kg/m2). Grooving where the bra straps sit on the shoulder. Aesthet Surg J. 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. J Plast Surg Hand Surg. 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. } Obstet Gynecol Clin North Am. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. 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. 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. These preliminary findings need to be validated by well-designed studies. Aesthet Surg J. Reduction mammoplasty performed solely for cosmetic indications is considered by insurers to be not medically necessary treatment of disease and subject to the standard cosmetic surgery plan exclusion. All patients underwent routine investigations to exclude secondary causes of gynecomastia. Long-term functional results after reduction mammoplasty. Is breast reduction covered by health insurance? | ASPS Reduction mammaplasty: A review of managed care medical policy coverage criteria. padding: 10px; Gland Surg. 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. 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. 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. 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. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. N Engl J Med. The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. He and associates (2011) examined the safety and feasibility of vacuum-assisted biopsy device in the treatment of gynecomastia. Plast Reconstr Surg. Kalliainen LK; ASPS Health Policy Committee. background-color: #663399; 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. 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. They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. Laituri CA, Garey CL, Ostlie DJ, et al. Breast cancer found at the time of breast reduction. 2006;118(4):840-848. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. 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. 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. He Q, Zheng L, Zhuang D, et al. #closethis { Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. 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. Kerrigan CL, Collins ED, Kneeland TS, et al. Treatment of adolescent gynecomastia. /*margin-bottom: 43px;*/ .fixedHeaderWrap { Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. Often times, insurance company will dictate how much breast tissue to be removed. Ann Chir Plast Esthet. The characteristics of patients as well as the curative effects between the 2 groups were analyzed. Abnormalities in Adolescent Breast Development. 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. 1998;41(3):240-245. The safety, efficacy, complications, and patient satisfactions were recorded during post-operative follow-up periods. 1996;20(5):391-397. J Am Coll Surg. 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. 2008;32(1):38-44. li.bullet { 2015;75(4):383-387. 1997;185(6):593-603. Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. No necrosis, systemic infection, or muscle paralysis was reported. Abnormal histopathological findings were more frequent in patients with reduction mammoplasty performed prior to oncological treatment (p < 0.001), and in patients with immediate reconstruction (p = 0.0064). margin-bottom: 38px; All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). Redundant skin was observed in 1 patient at 1 month post-operatively, whose breast, defined as grade-III, was the largest before operation. .strikeThrough { These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). 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. Plast Reconstr Surg. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. .headerBar { Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. 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. This will be computed based on your body area. Breast Pump & Breastfeeding Insurance Coverage & Resources | Aetna 2019;166(5):934-939. 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. @media print { 2014b;48(5):334-339. 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. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). 2010;45(3):650-654. 1998;101(2):361-364. Risk factors for complications following breast reduction: Results from a randomized control trial. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. 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.