aetna breast reduction requirements

of the following criteria must be met: Burdette TE, Kerrigan CL, Homa KA. hr.separator { 2007;36(2):497-519. Obstet Gynecol Clin North Am. 2020 Sep 4 [Online ahead of print]. Policy. 2015;75(4):370-375. color: blue!important; The Breast: Comprehensive Management of Benign and Malignant Diseases. This may lead to additional scarring and additional operating time. color: blue This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. Nguyen JT, Wheatley MJ, Schnur PL, et al. Prepubertal gynecomastia linked to lavender and tea tree oils. 2008;32(1):38-44. 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. Breast asymmetries: A brief review and our experience. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . 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). Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. Am J Infect Control. background-color: #663399; 1995;95(6):1029-1032. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. Links to various non-Aetna sites are provided for your convenience only. 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. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. Analysis was on an intention-to-treat basis. 2008;61(5):493-502. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. 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). This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. } The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. Gonzalez FG, Walton RL, Shafer B, et al. } These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. .strikeThrough { The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. 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. display: none; Breast pumps. Coding Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). .strikeThrough { Kerrigan CL, Collins ED, Kim HM, et al. } 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). All studies on the subject were evaluated for inclusion and 6 studies were included in the review. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. Risk factors for complications following breast reduction: Results from a randomized control trial. 2015;49(6):311-318. 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. How to Get Your Breast Reduction Covered By Insurance - RealSelf News Ann Plast Surg. padding-bottom: 4px; Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Handschin AE, Bietry D, Hsler R, 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. 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. If reduction mammoplasty was performed before oncological treatment, the incidence of abnormal findings was higher. 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 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. Recommended criteria for insurance coverage of reduction mammoplasty. Liposuction assisted gynecomastia surgery with minimal periareolar incision: A systematic review. Evidence-based clinical practice guideline: Reduction mammaplasty. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. Sugrue and associates (2015) evaluated the current practice patterns of drains usage by plastic and reconstructive and breast surgeons in United kingdom (UK) and Ireland performing bilateral breast reduction (BBR). Washington, DC: ACOG; 2011:121-122. 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). Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. Am Surg. A total of 15 articles met the inclusion criteria for review. Plastic Reconstr Surg. Qu and colleagues (2020) examined the effectiveness of vacuum-assisted breast biopsy systems for the treatment of gynecomastia. My Experience of Having Breast Reduction Surgery - Health Gland Surg. Patient demographics, surgical technique, and outcomes were analyzed. Horm Res Paediatr. 1995;34(2):113-116. Aetna considers breast reconstructive surgery to correct The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. 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. Reduction mammaplasty. 2014b;48(5):334-339. 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. Jones SA, Bain JR. Review of data describing outcomes that are used to assess changes in quality of life after reduction mammaplasty. Philadelphia, PA: W.B. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. 2007;119(4):1159-1166. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. Blomqvist L, Eriksson A, Brandberg Y. The primary outcome was the difference in wound drainage over 24 hours. Brown DM, Young VL. /*margin-bottom: 43px;*/ Gynecomastia may be drug-induced. 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. 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. background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; Plast Reconstr Surg. Measuring health state preferences in women with breast hypertrophy. Plast Reconstr Surg. 40 . 2001;107(5):1234-1240. 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. Narula HS, Carlson HE. Does Health Insurance Cover Breast Reduction Surgery? - GoodRx Ann Plastic Surg. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. J Plast Surg Hand Surg. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. Aesthet Surg J. PLoS One. The surgeon estimates that at least the following amounts (in grams) of breast tissue, not fatty tissue, will be removed from each breast, based on the member's body surface area (BSA) calculated using theMosteller formula. Alternatively, you may qualify if your breast size causes significant symptoms, such as: Long-term neck, shoulder or neck pain. }. The Mammotome procedure represented another novel therapeutic option for gynecomastia. 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. .fixedHeaderWrap { 1. OL OL LI { OL LI { Sollie M. Management of gynecomastia-changes in psychological aspects after surgery-a systematic review. Tang CL, Brown MH, Levine R, et al. outline: none; 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. 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). A follow-up study of 105 women with breast cancer following reduction mammaplasty. Surgeon. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. Macromastia: all . The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. Choban PS, Heckler R, Burge JC, Flancbaum L. Increased incidence of nosocomial infections in obese surgical patients. 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. 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. 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. 2007;356(5):479-485. list-style-type: decimal; Beer GM, Kompatscher P, Hergan K. Diagnosis of breast tumors after breast reduction. Aesthetic Plast Surg. Current concepts in gynaecomastia. Nelson JA, Fischer JP, Chung CU, et al Obesity and early complications following reduction mammaplasty: An analysis of 4545 patients from the 2005-2011 NSQIP datasets. J Plast Surg Hand Surg. No necrosis, systemic infection, or muscle paralysis was reported. } Level of Evidence = IV. PDF 0185 Breast Reconstructive Surgery (1) - Aetna Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. Tang CL, Brown MH, Levine R, et al. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. 1969;44(235):291-303. list-style-type: lower-alpha; You may be able to buy a breast pump and supplies from one of our medical equipment suppliers at no charge or at a discounted rate. (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) Ann Plast Surg. 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%. Sixteen (23%) patients had complications and higher resection weight, increased BMI, and older age were found to have statistically significant complication rates with p-values of p<0.001, p=0.034, and p=0.004, respectively.The investigators also found that the incidence of complications was highest among current smokers and lowest among those who had never smoked with a 37% difference in the occurrence of complication (p<0.01). Follow-up ranged from 2 months to 3 years. Plast Reconstr Surg. 2018;7(Suppl 1):S70-S76. Please check your insurance policy to see whether breast reduction is a covered procedure. 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. It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. 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. 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. padding-right: 18px; Fan L, Yang X, Zhang Y, Jiang J. Endoscopic subcutaneous mastectomy for the treatment of gynecomastia: A report of 65 cases. Plast Reconstr Surg. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. Each surgeon who participated in the study reported on the height, weight, and volume of reduction of their last 15 to 20 patients, and each surgeon provided their intuitive sense regarding the motivation of each patient for breast reduction surgery. 1993;91(7):1270-1276. color: white; # font-weight: bold; Oncoplastic reduction mammoplasty for breast cancer in women with macromastia: Oncological long-term outcomes. CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the Vacuum-assisted minimally invasive mastectomy was performed successfully in all cases, with no residual glands or adipose tissue observed on US. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. Clinical outcomes were measured by operative subjects' responses to a questionnaire about symptoms and quality of life. Cochrane Database Syst Rev. 1994;21(3):539-543. Level of Evidence = III. Plast Reconstr Surg. Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. The health burden of breast hypertrophy. 2013;71(5):471-475. 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. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. .newText { .headerBar { Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. A total of 244 out of 1,628 patients with the average age of 23.13 years. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. Srinivasaiah N, Iwuchukwu OC, Stanley PR, et al. Ann Chir Plast Esthet. A physician-supervised diet and exercise plan may be indicated in obese patients. Hoyos AE, Perez ME, Dominguez-Millan R, et al. A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery. 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). PDF Clinical Policy Bulletin: Cosmetic Surgery - Aetna All patients underwent routine investigations to exclude secondary causes of gynecomastia. American Society of Plastic Surgeons (ASPS). Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. OL OL OL OL LI { margin-bottom: 38px; Breast reduction surgery, also known as reduction mammaplasty, removes fat, breast tissue and skin from the breasts. border-width:0; 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. Breast reduction surgery is considered cosmetic for all indications not listed in section I, A. Kasielska-Trojan A, Danilewicz M, Antoszewski B. PDF Procedures, programs and drugs you must precertify - AmeriBen 2015;10(8):e0136094. Harmonic scalpel versus electrocautery in breast reduction surgery: A randomized controlled trial. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Gynecomastia in patients with prostate cancer: Update on treatment options. 2011;128(4):243e-249e. 2006;30(3):309-319. Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass 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. 2019;166(5):934-939. 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. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . Treating providers are solely responsible for medical advice and treatment of members. Arch Dis Child. Guidelines for Adolescent Health Care. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. Disproportionately large breasts can cause both physical and emotional . Aetna Coverage Denial - 2nd Appeal (They said I'm overweight) Criteria for reduction mammoplasty surgery from the American Society of Plastic Surgeons (ASPS, 2002; ASPS, 2011) states, among other things, that breast weight or breast volume is not a legitimate criterion upon which to distinguish cosmetic from functional indications. Gynecomastia in patients with prostate cancer: A systematic review. Ann Plastic Surg. For medical border-radius: 4px; 2006;118(4):840-848. 2000;106(2):280-288. Reduction mammoplasty or breast reduction surgery reduces the volume and weight of the female breasts by removing excess fat, glandular tissue and skin. These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. # color: white; 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. ol.numberedList LI { Bland KI, Copeland EM, eds. 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. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. Surgical treatment of primary gynecomastia in children and adolescents. Qu S, Zhang W, Li S, et al. 2001;108(6):1591-1599. Pediatr Surg Int. Is breast reduction covered by health insurance? | ASPS Krieger LM, Lesavoy MA. } Endocrinol Metab Clin North Am. Gland Surg. 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. Glatt BS, Sarwer DB, O'Hara DE, et al. Chadbourne EB, Zhang S, Gordon MJ, et al. 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. right: 30px; } Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. } Kasielska-Trojan and associates (2018) analyzed digit ratio in relation to estrogen receptor (ER) and progesterone receptor (PR) expression and verified digit ratio (2D: 4D) as a marker of ER and PR over-expression in the male breast. Magnetic Resonance Imaging (MRI) of the Breast - Aetna Reduction mammoplasty: Cosmetic or reconstructive procedure? Breast Reduction Surgery | Johns Hopkins Medicine