aetna breast reduction requirements aetna breast reduction requirements

This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. A physician-supervised diet and exercise plan may be indicated in obese patients. 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. 2018;89(6):408-412. 1999;103(6):1687-1690. A detailed drug history, including list of medications, an assessment of indirect or environmental exposure to estrogenic compounds, and recreational drug use. They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. 1969;44(235):291-303. 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. Fischer JP, Cleveland EC, Shang EK, et al. There were no restrictions on the basis of date or language of publication. The majority (87.7 %) of cases presented with accompanying mastalgia. 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. 2000;45(6):575-580. 01/04/2023 right: 30px; Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). 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). Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. American Society of Plastic Surgeons (ASPS). Gynecomastia surgery is the surgical correction of over-developed or enlarged breasts in men. color: #FFF; 2009;19(3):e85-e90. 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: Plastic Reconstruct Surg. background-color: #663399; Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. Plastic Reconstr Surg. 2015;49(6):363-366. Level of Evidence = IV. Three review authors undertook independent screening of the search results. The study subjects were stratified into groups based on ages of <60 years and 60 years. Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . Surgical implications of obesity. Bland KI, Copeland EM, eds. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. 2008;32(1):38-44. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Patients with abnormal histopathology could not be pre-operatively identified based on demographics. 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. 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). Plast Reconstr Surg. 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. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. It was also found that only 3 % of subjects reported that they had no aesthetic motivation for surgery. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. Oxfordshire NHS Trust. } A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. 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. Breast asymmetries: A brief review and our experience. Plast Reconstr Surg. 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). Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. Gynecomastia: A systematic review. color: white; After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. Other just require 500 grams no matter what your height and weight. Ann Plast Surg. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. 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. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. (25 y/o female with a 38J bra size) according to aetna, I should more than qualify for a reduction as I have back, neck, shoulder pain, chest pain and pressure, arm numbness while laying on sides, etc. Redundant skin was observed in 1 patient at 1 month post-operatively, whose breast, defined as grade-III, was the largest before operation. If an insufficient amount of breast tissue is removed, the surgery is less likely to be successful in relieving pain and any related symptoms from excessive breast weight (e.g., excoriations, rash). Breast hypertrophy. Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). 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. Collins ED, Kerrigan CL, Kim M, et al. Philadelphia, PA: W.B. Breast cancer found at the time of breast reduction. 2006;30(3):309-319. Plast Reconstr Surg. Breast Concerns of Adolescents. .strikeThrough { Statistical analysis was performed with student t-test and chi-square test. The safety, efficacy, complications, and patient satisfactions were recorded during post-operative follow-up periods. 1997;100(4):875-883. However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. The health burden of breast hypertrophy. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. 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). In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). In a systematic review, these investigators examined the role of radiotherapy in this context. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Breast reduction surgery might also help improve self-image and the ability to take part in physical activities. Analysis was on an intention-to-treat basis. 1995;95(1):77-83. 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. list-style-type: upper-roman; Evidence-based clinical practice guideline: Reduction mammaplasty. 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. Principles of breast re-reduction: A reappraisal. 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. 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. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. In a review on Surgical treatment of primary gynecomastia in children and adolescents, Fischer et al (2014b) concluded that surgical correction of gynecomastia remains a purely elective intervention. Major complications (1.6 %) included unilateral hematoma and localized infection. } Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . 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. Anesthesia may be injected along with saline solution until the tissue is firm, and a suction cannula is used to extract fat from the breast. Several important points should be considered in evaluating these challenges to insurers' criteria for breast reduction surgery. The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. Two review authors undertook independent data extraction of study characteristics, methodological quality and outcomes (e.g., infection, other wound complications, pain, and length of hospital stay [LOS]). Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. 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. Approximately 25 % of the 49 subjects included in this study did not return the post-operative questionnaire. @media print { display: none; Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? 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. Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. 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. 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. Gonzalez FG, Walton RL, Shafer B, et al. background: #5e9732; Handschin AE, Bietry D, Hsler R, et al. If reduction mammoplasty was performed before oncological treatment, the incidence of abnormal findings was higher. background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; Breast reduction outcome study. These studies did not find a relationship between breast weight or amount of breast tissue removed and the likelihood of response or magnitude of relief of pain after reduction mammoplasty. 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). Ages ranged from 18 to 66 years. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. Aesthetic Plast Surg. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. Initial breast reconstruction including augmentation with implants 15771-15772 (when specific to breast), 19325, 19340, 19342, C1789 Fat grafting (alone, or with implant based feminization) 15771, 15772 *Note: CPT 19318 (breast reduction) includes the work necessary to reposition and reshape the nipple . Kalliainen LK; ASPS Health Policy Committee. 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. 2010;125(5):1301-1308. 2002;109(5):1556-1566. 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. A population-level analysis of bilateral breast reduction: does age affect early complications? Surgery. Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). .fixedHeaderWrap { Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. 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:. and areola. 1997;185(6):593-603. Tang CL, Brown MH, Levine R, et al. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. margin-top: 38px; Narula HS, Carlson HE. width: 100%; J Plast Reconstr Aesthet Surg. Washington, DC: ACOG; 2011:121-122. 1995;95(6):1029-1032. These investigators retrospectively examined 83 patients with gynecomastia between January 2015 and December 2019. All patients underwent routine investigations to exclude secondary causes of gynecomastia. 2009;62(2):195-199. A follow-up study of 105 women with breast cancer following reduction mammaplasty. Reduction mammoplasty: Criteria for insurance coverage. Coding Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. Patient demographics, surgical technique, and outcomes were analyzed. For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. 2014b;30(6):641-647. 1995;61(11):1001-1005. This will be computed based on your body area. #backTop:hover { Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. Qu S, Zhang W, Li S, et al. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. Asian J Surg. Howrigan P. Reduction and augmentation mammoplasty. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. 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 Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. 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. The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. The Mammotome procedure represented another novel therapeutic option for 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. 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. However, it is unclear if there is any evidence to support this practice. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. Gynecomastia may be drug-induced. 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 authors concluded that this study was the largest to-date examining the role of tamoxifen in idiopathic gynecomastia, and these findings showed approximately 9 in every 10 men treated with tamoxifen therapy had successful resolution of their symptoms. There were only 2 studies of a total 25 patients that were considered as good in quality. 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. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . 1993;17(3):211-223. Brown DM, Young VL. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. 1998;49:215-234. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. Plast Reconstr Surg. 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. No statistically significant differences in the drainage, level of pain, size of open areas, clinical appearance, degree of scar pliability, or scar erythema were noted. Special Clinical Concerns. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. .newText { An average of 320 specimens were excised from each side with mean blood loss of 34 ml. Aesthetic Plast Surg. Policy. 2014b;48(5):334-339. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. Behmand RA, Tang DH, Smith DJ Jr. Outcomes in breast reduction surgery. 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%. 2016;20(3):256-260. 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.