aetna breast reduction requirements

Macromastia: all . Prostate Cancer Prostatic Dis. 2015;10(8):e0136094. Copyright Aetna Inc. All rights reserved. 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. Analysis was on an intention-to-treat basis. Nelson et al (2014b) separately conducted a population level analysis of the 2005-2011 NSQIP datasets, identifying patient who underwent reduction mammoplasty, to determine the impact of obesity on early complications after reduction mammoplasty. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. The nipple-areola complex was re-positioned in 60 % of patients (n = 54). } Mizgala CL, MacKenzie KM. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. 40 . Furthermore, you must test negative for breast cancer on a mammogram a maximum of two years before your surgery if you are 50 or older. In addition, Nguyen et al (2004) ignored a wealth of published evidence of the effectiveness of physical therapy, analgesics and other conservative measures on back and neck pain generally. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. 01/04/2023 Another set of breast pump supplies if you get pregnant . Variations in pattern of pubertal changes in girls. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. text-decoration: underline; 1998;101(2):361-364. 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.. 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. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. The control group was not followed longitudinally or treated according to any protocol to ensure that they received optimal conservative management; conclusions about the lack of effectiveness of conservative management were based on their responses to a questionnaire about whether subjects tried any of 15 conservative interventions, and whether or not they thought these interventions provided relief of symptoms. Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. The following factors were independently associated with any surgical complications: morbid obesity (odds ratio [OR], 2.1; P < .001), active smoking (OR, 1.7; P < .001), history of dyspnea (OR, 2.0; P < .001), and resident participation (OR, 1.8; P = .01) while factors associated with major complications included active smoking (OR, 2.7; P < .001), dyspnea (OR, 2.6; P < .001), resident participation (OR, 2.1; P < .001), and inpatient surgery (OR, 1.8; P = .01). Aesthet Surg J. 1994;21(3):539-543. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . 2007;356(5):479-485. Handschin AE, Bietry D, Hsler R, et al. Plastic Reconstruct Surg. GP Notebook. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Surgical implications of obesity. Li CC, Fu JP, Chang SC, et al. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. 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. 1997;185(6):593-603. The investigators found little difference between obese and non-obese women concerning patient's reports of resolution of symptoms and improvement in body image. Breast reduction surgery might also help improve self-image and the ability to take part in physical activities. Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. cursor: pointer; Gynecomastia in patients with prostate cancer: Update on treatment options. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. Cochrane Database Syst Rev. #backTop:hover { Three review authors undertook independent screening of the search results. background-color: #663399; 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. 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 researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. A total of 81 patients were included in this study. 1999;103(1):76-82; discussion 83-85. Plastic Reconstr Surg. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. The majority (87.7 %) of cases presented with accompanying mastalgia. Mannu GS, Sudul M, Bettencourt-Silva JH, et al. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). Vacuum-assisted minimally invasive mastectomy was performed successfully in all cases, with no residual glands or adipose tissue observed on US. display: block; Khan SM, Smeulders MJ, Van der Horst CM. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. 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. J Plast Surg Hand Surg. The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. Plastic Reconstr Surg. Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. list-style-type: upper-alpha; Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammaplasty. J Plast Reconstr Aesthet Surg. Sood R, Mount DL, Coleman JJ 3rd, et al. Yao Y, Yang Y, Liu J, et al. 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. For individuals who received radiation treatment to the chest . Aesthetic Plast Surg. of . In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. Surg Laparosc Endosc Percutan Tech. Raispis T, Zehring RD, Downey DL. 2021;147(5):1072-1083. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. 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. 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. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. Leclere FM, Spies M, Gohritz A, Vogt PM. padding: 10px; The investigators reported that subjects who were of normal weight were as likely to report benefit from reduction mammoplasty as subjects who were over-weight. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; A total of 244 out of 1,628 patients with the average age of 23.13 years. In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. 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). 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. } Links to various non-Aetna sites are provided for your convenience only. Priorities Forum Policy Statement. .arrowPurpleSmall, a:hover.arrowPurpleSmall { Last Review01/04/2023. No other operation-related complications were observed. 2006;30(3):309-319. ol.numberedList LI { In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. Approximately 25 % of the 49 subjects included in this study did not return the post-operative questionnaire. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. position: fixed; Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. Mistry RM, MacLennan SE, Hall-Findlay EJ. list-style-type: lower-roman; 2021 Aug 11 [Online ahead of print]. Gynecomastia: A systematic review. 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. A total of 90 patients underwent breast re-reduction surgery. .headerBar { Gynecomastia has been classified into2 types. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. J Plast Surg Hand Surg. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. First, the opinions and guidelines of medical professional organizations and consensus groups are considered according to the quality of the scientific evidence and supporting rationale. This will be computed based on your body area. } hr.separator { Women's Health and Cancer Rights Act of 1998. 2008;121(4):1092-1100. These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). and areola. list-style-type: decimal; 2012;130(4):785-789. The safety, efficacy, complications, and patient satisfactions were recorded during post-operative follow-up periods. Plast Reconstr Surg. Administration of Benefits and Transition Responsibilities top: 0px; Aesthetic Plast Surg. 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. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. Reduction mammoplasty improves symptoms of macromastia. Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. 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). The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. Patient demographics, surgical technique, and outcomes were analyzed. Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. A lack of correlation between these variables may result from the fact that the analyzed group of men with idiopathic gynecomastia was small in number, but at the same time, it appeared to be homogenous in these aspects (positive ER and/or PR expression and high digit ratio). Secondary outcomes included subjective as well as objective assessments of pain and wound healing. Level of Evidence = IV. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. 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). Am J Infect Control. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. The Breast: Comprehensive Management of Benign and Malignant Diseases. Breast cancer found at the time of breast reduction. 1995;61(11):1001-1005. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. No new trials were identified for this first update. For medical Note: Breast reduction surgery will be considered medically necessary for women meeting the symptomatic criteria specified above, regardless of BSA, with more than 1 kg of breast tissue to be removed per breast. 1991;27(3):232-237. Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, . Schnur PL, Schnur DP, Petty PM, et al. Burns JL, Blackwell SJ. The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. .fixedHeaderWrap { 2014a;34(3):409-416. The American Society for Plastic Surgery (2011) advises to delay surgery until breast growth ceases: Although waiting may prolong the psychological awkwardness, it is advisable to delay surgery until breast growth ceases in order to achieve the best result. This is similar tothe American College of Obstetricians and Gynaecologists'2011 Guidelines forAdolescent Health Care chapter on breast concerns in adolescents, which states regarding breast hypertrophy: Preferably, treatment should be deferred until breast growth has been completed. Most UnitedHealthcare plans have a specific exclusion for breast reduction surgery except as required by the . 2010;125(5):1301-1308. font-size: 18px; Pseudo-gynecomastia refers to excessive fat tissue or prominent pectoralis muscles. Tang CL, Brown MH, Levine R, et al. Reduction mammoplasty for asymptomatic members is considered cosmetic. Howrigan P. Reduction and augmentation mammoplasty. 1969;44(235):291-303. Surgical treatment of primary gynecomastia in children and adolescents. Oxford, UK: National Health Service (NHS); October 2008. 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). Kerrigan CL, Collins ED, Striplin D, et al. Breast reduction for symptomatic macromastia. The end-point was the complete resolution of gynecomastia. Breast J. } # color: white; The authors concluded that gynecomastia treatment combining high-definition liposculpture to male breast tissue resection via a new, almost invisible incision allowed these researchers to achieve an athletic and natural appearance of the male pectoral area with a very low rate of complications. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. Asian J Surg. list-style-type: upper-roman; Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). The American Society of Plastic Surgeons' evidence-based clinical practice guideline on reduction mammoplasty (ASPS, 2011) states thatin standard reduction mammoplasty procedures, evidence indicates that the use of drains is not beneficial. 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. Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. In total there were 306 women in the 3 trials, and 505 breasts were studied (254 drained, and 251 who were not drained). 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. Ann Plast Surg. Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). 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. However, these medications should be reserved for those with no decrease in breast size after 2 years. The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia. Prepubertal gynecomastia linked to lavender and tea tree oils. The requirement for coverage is that the amount of breast tissue to be removed has to be enough to improve your symptoms or function. Surgical treatment is indicated when medical treatments fail. A detailed drug history, including list of medications, an assessment of indirect or environmental exposure to estrogenic compounds, and recreational drug use. 2001;108(1):62-67. Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne Saunders Co.; 1991. z-index: 99; Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. For many patients the psychological impact of the disease is substantial. In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. OL OL OL OL OL LI { 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). Ann Plastic Surg. The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. Ann Plastic Surg. color: red Bertin ML, Crowe J, Gordon SM. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. 2017;139(6):1313-1322. 1995;34(2):113-116. For these reasons, there is insufficient evidence to support the use of reduction mammoplasty, without regard to the size of the breasts or amount of breast tissue to be removed, as a method of relieving chronic back, neck, or shoulder pain. Qu S, Zhang W, Li S, et al. Gynaecomastia. However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. A total of 15 articles met the inclusion criteria for review. 2012;69(5):510-515. To calculate body surface area (BSA) see:BMI and BSA (Mosteller) Calculator;orBSA (m2) = ([height (in) x weight (lb)]/3131)(denotes square root), BSA (m2) = ([height (cm) x weight (kg)]/3600)(denotes square root). 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. 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. Mayo Clin Proc. Gland Surg. Radiotherapy for prevention or management of gynecomastia recurrence: Future role for general gynecomastia patients in plastic surgery given current role in management of high-risk prostate cancer patients on anti-androgenic therapy. When seeking preauthorization for a breast reduction, your goal is generally twofold. The operation was successfully performed in all 20 patients with a mean operating time of 51 mins and a hospital stay of 4 days. Because reduction mammoplasty may be used for both medically necessary and cosmetic indications, Aetna has set forth above objective criteria to distinguish medically necessary reduction mammoplasty from cosmetic reduction mammoplasty. 1999;103(6):1687-1690. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. 1997;100(4):875-883. 2018;24(6):1043-1045. Collis N, McGuiness CM, Batchelor AG. 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. The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. Recommended criteria for insurance coverage of reduction mammoplasty. Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. Annu Rev Med. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. 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. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. list-style-type: lower-alpha; 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). This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. 2009;62(2):195-199. 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). 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. 2018;89(6):408-412. Gland Surg. 2005;55(3):227-231. Laituri CA, Garey CL, Ostlie DJ, et al. 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). Ann Plast Surg. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. 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. The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. ASPS clinical practice guideline summary on reduction mammaplasty. 2006;118(4):840-848. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. 1998;49:215-234. 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 reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. 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). Hoyos AE, Perez ME, Dominguez-Millan R, et al. ASPS Recommended Coverage Criteria for Third Party Payors. li.bullet { @media print { 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].

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