2015;49(6):311-318. Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. 2008;61(5):493-502. PDF Clinical Policy Bulletin: Cosmetic Surgery - Aetna Breast Reduction Surgery | Johns Hopkins Medicine Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. Pain/discomfort/ulceration from bra straps cutting into shoulders; Skin breakdown (severe soft tissue infection, tissue necrosis, ulceration hemorrhage) from overlying breast tissue; There is a reasonable likelihood that the member's symptoms are primarily due to macromastia; Reduction mammoplasty (also spelled as 'mammaplasty') is likely to result in improvement of the chronic pain; Pain symptoms persist as documented by the physician despite at least a 3-month trial of therapeutic measures such as: Analgesic/non-steroidal anti-inflammatory drugs (NSAIDs) interventions and/or muscle relaxants, Dermatologic therapy of ulcers, necrosis and refractory infection, Physical therapy/exercises/posturing maneuvers, Supportive devices (e.g., proper bra support, wide bra straps), Chiropractic care or osteopathic manipulative treatment. Plast Reconstr Surg. 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: Breast reduction surgery - Mayo Clinic # font-weight: bold; Howrigan P. Reduction and augmentation mammoplasty. OL OL LI { Arlington Heights, IL: ASPS; March 9, 2002. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. Treating providers are solely responsible for medical advice and treatment of members. Breast cancer found at the time of breast reduction. 2000;44(2):125-134. text-decoration: underline; Narula HS, Carlson HE. 2000;106(2):280-288. Vacuum-assisted minimally invasive mastectomy was performed successfully in all cases, with no residual glands or adipose tissue observed on US. list-style-type: upper-roman; For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. bottom: 20px; /*margin-bottom: 43px;*/ Often, you'll be eligible for Blue Cross Blue Shield breast reduction coverage if your surgeon plans to remove at least 500 grams of breast tissue per breast. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). 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). list-style-type: decimal; Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. PDF A look at new changes coming to E&M and breast coding in 2021 Kalliainen LK; ASPS Health Policy Committee. 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. Ann Plastic Surg. Med Decis Making. 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. This Clinical Policy Bulletin may be updated and therefore is subject to change. Reduction mammoplasty or breast reduction surgery reduces the volume and weight of the female breasts by removing excess fat, glandular tissue and skin. Does Health Insurance Cover Breast Reduction Surgery? - GoodRx J Laparoendosc Adv Surg Tech A. A total of 15 articles met the inclusion criteria for review. Refer to the member's specific plan document for applicable coverage. 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. background: #5e9732; Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. 01/04/2023 Breast reduction outcome study. Sugrue CM, McInerney N, Joyce CW, et al. 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 Patients with abnormal histopathology could not be pre-operatively identified based on demographics. Aesthetic Plast Surg. The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. 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. All RCTs that compared the use of a wound drain with no wound drain following plastic and reconstructive surgery of the breast (breast augmentation, breast reduction and breast reconstruction) in women were eligible. Reduction mammoplasty improves symptoms of macromastia. Clinical outcomes were measured by operative subjects' responses to a questionnaire about symptoms and quality of life. Philadelphia, PA: W.B. No necrosis, systemic infection, or muscle paralysis was reported. Mistry RM, MacLennan SE, Hall-Findlay EJ. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. Karamanos et al (2015) identified their study as the largest sample on breast reduction in the literature, in which age and surgeon specialty did not correlate with negative results. Fischer et al (2014a) evaluated predictors of postoperative complications following reduction mammoplasty using the NSQIP) data sets. Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. 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. cursor: pointer; How to Get Your Breast Reduction Covered By Insurance - RealSelf News 1969;44(235):291-303. Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. list-style-type : square !important; 2nd ed. Type II gynecomastia is more generalized breast enlargement. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. PDF Breast Reduction Surgery and Gynecomastia Surgery - Aetna color: blue 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. Approximately 25 % of the 49 subjects included in this study did not return the post-operative questionnaire. 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. Hoyos AE, Perez ME, Dominguez-Millan R, et al. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. Kerrigan CL, Collins ED, Kneeland TS, et al. The average age of the studied individuals was 25.7 years (SD = 7.8); ER and PR expression was detected in breasts, and digit ratios were calculated in patients with idiopathic gynecomastia. right: 30px; Aesthet Surg J. Laituri CA, Garey CL, Ostlie DJ, et al. ER expression did not correlate with the right (p = 0.51) and left 2D: 4D (p = 0.97). Early complications were rare (6.1%), with superficial skin and soft tissue infections accounting for 45.8% of complications. This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. Bertin ML, Crowe J, Gordon SM. 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. Ann Plast Surg. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. 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. 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. Nelson et al (2014a) analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Plast Reconstr Surg. The vacuum-assisted breast biopsy system is an effective strategy for the treatment of gynecomastia. OL OL OL OL LI { An average of 320 specimens were excised from each side with mean blood loss of 34 ml. The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. 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 2012;130(4):785-789. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. Arlington Heights, IL: ASPS; 2011. } Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. This was further isolated when comparing morbidly obese patients to non-obese (p < 0.001), class I (p < 0.001), and class II (p = 0.01) patients. border-width:0; Schnur PL, Hoehn JG, Ilstrup DM, et al. Reduction mammaplasty: The need for prospective randomized studies. 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. 2018;24(6):1043-1045. Breast pumps. PDF Clinical Policy Bulletin: BRCA Testing, Prophylactic Mastectomy - Aetna 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. Variations in pattern of pubertal changes in girls. } Socioeconomic Committee Position Paper. 2019;166(5):934-939. Reduction mammoplasty: Cosmetic or reconstructive procedure? Insurers have commonly used the amount of breast tissue to be removed as a criterion for evaluating the medical necessity of breast reduction surgery. The author concluded that the current level of evidence on this subject was very low and future studies, examining the impact of the surgical intervention for gynecomastia on psychological domains, are greatly needed. A study by Bruhlmann and Tschopp (1998) was a retrospective study of 246 patients from a surgical practice, approximately 50 % (132) of whom returned a questionnaire about their symptoms and satisfaction with aesthetic results, and their recollection of symptoms prior to surgery. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. 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). Prostate Cancer Prostatic Dis. Mannu GS, Sudul M, Bettencourt-Silva JH, et al. 1996;20(5):391-397. Khan SM, Smeulders MJ, Van der Horst CM. For example, at a body surface area of 1.5m, Aetna requires a minimum weight of 385 grams removed from each breast, whereas the Schnur scale would only require 260g. Liposuction assisted gynecomastia surgery with minimal periareolar incision: A systematic review. A total of 90 patients underwent breast re-reduction surgery. Chadbourne EB, Zhang S, Gordon MJ, et al. In other patients, excess skin and nipple and areola relocation are necessary. 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. 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. Level of Evidence = IV. Evidence-based clinical practice guideline: Reduction mammaplasty. Little is known about the effect of surgical treatment on the psychological aspects of the disease. Leclere FM, Spies M, Gohritz A, Vogt PM. 2010;125(5):1301-1308. Br J Plast Surg. } 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. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. 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. The average age was 24.7 years (range of 18 to 47 years). American Society of Plastic Surgeons (ASPS). Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: A review. They stated that in the light of these findings, contralateral reduction mammoplasty with histopathological evaluation in breast cancer patients offered a sophisticated tool to catch those patients whose contralateral breast needs increased attention. A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. 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. 18th ed. 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. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. 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. li.bullet { 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. Reduction mammaplasty: A review of managed care medical policy coverage criteria. Also, there was no correlation between PR expression and 2D: 4D. Miller AP, Zacher JB, Berggren RB, et al. There were 18 out of 415 studies eligible to review. Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. It is not intuitively obvious, however, that breast weight would substantially contribute to back, neck and shoulder pain in women with normal or small breasts. 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. Mayo Clin Proc. Saunders Co.; 1991. These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. OL OL OL LI { 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. Priorities Forum Policy Statement. Three review authors undertook independent screening of the search results. Management of gynecomastia should include evaluation, including laboratory testing, to identify underlying etiologies. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. A non-standardized survey showed a very high satisfaction index. PDF Gender Dysphoria Treatment - Cigna A follow-up study of 105 women with breast cancer following reduction mammaplasty. This may lead to additional scarring and additional operating time. The end-point was the complete resolution of gynecomastia. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. Patient demographics, surgical technique, and outcomes were analyzed. Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. Principles of breast re-reduction: A reappraisal. CG-SURG-71 Reduction Mammaplasty - Anthem The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. A population-level analysis of bilateral breast reduction: does age affect early complications? 2014;20(3):274-278. 1998;49:215-234. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. 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. Plastic surgery for teenagers briefing paper. .strikeThrough { Townsend: Sabiston Textbook of Surgery. } Collis N, McGuiness CM, Batchelor AG. 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. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. 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. 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., breastsize stable over one year) when any of the following criteria (A, B, or C) is met: Member has persistent symptoms in at leasttwoof the anatomical body areas below, directly attributed to macromastia and affecting daily activities for at least1 year: Member has severe breast hypertrophy, documented by high-quality color frontal-view and side-view photographs;and, Women50 years of age or older are required to have a mammogram that was negative for cancer performed within the twoyears prior to the date of the planned reduction mammoplasty;and. 2009;19(3):e85-e90. J Plast Reconstr Aesthet Surg. 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. 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. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). Nguyen JT, Wheatley MJ, Schnur PL, et al. Choban PS, Heckler R, Burge JC, Flancbaum L. Increased incidence of nosocomial infections in obese surgical patients. Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. A physician-supervised diet and exercise plan may be indicated in obese patients. 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). Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne See Appendix for Table 1. Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. 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. Plast Reconstr Surg. Glatt BS, Sarwer DB, O'Hara DE, et al. Measuring health state preferences in women with breast hypertrophy. Obesity and complications in breast reduction surgery: Are restrictions justified? 2007;36(2):497-519. 2005;55(3):227-231. Does Blue Cross Blue Shield Cover Breast Reduction Surgery? - HelpAdvisor Level of Evidence = IV. Reduction mammoplasty for asymptomatic members is considered cosmetic. Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. Annu Rev Med. 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. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Most UnitedHealthcare plans have a specific exclusion for breast reduction surgery except as required by the . Based largely upon these results, Nguyen et al (2004) reached the conclusion that a trial of conservative management is not an appropriate criterion for insurance coverage, even though responses to the BRAVO questionnaire indicated that operative candidates and hypertrophy controls received at least some pain relief from all of the conservative interventions, and for some conservative interventions, virtually all subjects reported at least some pain relief. When seeking preauthorization for a breast reduction, your goal is generally twofold. I have recently met with my primary doctor after speaking to my insurance company (aetna) for months about getting a breast reduction. Collins ED, Kerrigan CL, Kim M, et al. Plast Reconstr Surg. Surgical treatment of primary gynecomastia in children and adolescents. Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). 2016;20(3):256-260. Gynecomastia: A systematic review. 1995;95(1):77-83. What are Aetna breast reduction requirements? - RealSelf.com Aetna's Itty Bitty Titty Committee - by Libby Watson - Sick Note