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. Surgical treatment of primary gynecomastia in children and adolescents. 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. The majority (87.7 %) of cases presented with accompanying mastalgia. 2007;119(4):1159-1166. PDF Breast Reduction Surgery - Commercial Medical Policy - UHCprovider.com The characteristics of patients as well as the curative effects between the 2 groups were analyzed. color: red!important; margin-bottom: 38px; 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. To get insurance coverage, you'll probably need . J Pediatr Surg. 2008;121(4):1092-1100. Analysis was on an intention-to-treat basis. Philadelphia, PA: W.B. Management of gestational gigantomastia. Socioeconomic Committee Position Paper. Plast Reconstr Surg. 2016;20(3):256-260. 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 J Plast Surg Hand 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. The health burden of breast hypertrophy. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . However, these medications should be reserved for those with no decrease in breast size after 2 years. Breast Concerns of Adolescents. Collins ED, Kerrigan CL, Kim M, et al. The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . 2018;24(6):1043-1045. Arlington Heights, IL: ASPRS; 1987. American Society of Plastic Surgeons (ASPS). 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). Fan L, Yang X, Zhang Y, Jiang J. Endoscopic subcutaneous mastectomy for the treatment of gynecomastia: A report of 65 cases. The surgeon must also certify that a certain weight of breast tissue (based on Aetna's table) will be removed in every breast, and not entirely fatty tissue. Jones SA, Bain JR. Review of data describing outcomes that are used to assess changes in quality of life after reduction mammaplasty. 2018;7(Suppl 1):S70-S76. Breast and aesthetic surgery. Does Aetna Cover Breast Reduction? | HelpAdvisor.com } Links to various non-Aetna sites are provided for your convenience only. display: block; .newText { PDF Clinical Policy Bulletin: BRCA Testing, Prophylactic Mastectomy - Aetna 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]). Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. Arch Dis Child. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). Although the BRAVO study is described as a controlled study, the "control" group is obtained, not from the same cohort, but from a separate cohort of individuals recruited from newspaper advertisements and solicitations at meetings for inclusion in a study of the population burden of breast hypertrophy; 75 % of this control group were obtained from2 centers, but the characteristics of those2 centers were not described. 1998;49:215-234. J Laparoendosc Adv Surg Tech A. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. 1969;44(235):291-303. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. 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. 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. In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. Can objective predictors for operative success be identified? 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. Annu Rev Med. 2015;(10):CD007258. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). Oxford, UK: National Health Service (NHS); October 2008. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. Plast Reconstr Surg. 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. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. .newText { 2 . Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. 2005;58(3):286-289. Breast Reduction Surgery: Procedure, Recovery, Cost, and More - Healthline Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. } 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. Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. 1991;27(3):232-237. 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. The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. No data were provided on loss to follow-up. Asian J Surg. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; right: 30px; Saunders Co.; 1991. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. Behmand RA, Tang DH, Smith DJ Jr. Outcomes in breast reduction surgery. 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. 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). 2019;8(4):431-440. 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. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. Bertin ML, Crowe J, Gordon SM. Burns JL, Blackwell SJ. Complication rates were inconsistent throughout the studies, ranging from 0.06 % to 26.67 %. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). 2008;61(5):493-502. color:#eee; Aetna considers breast reconstructive surgery to correct For many patients the psychological impact of the disease is substantial. Br J Plast Surg. z-index: 99; Furthermore, the lack of an expected "dose-response" relationship between the amount of breast tissue removed and the magnitude of symptomatic relief in these studies raises questions about the validity of these studies and the effectiveness of breast reduction as a method of relieving shoulder and back pain. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). 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. After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. The primary outcome was the difference in wound drainage over 24 hours. 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. They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. Resolution of idiopathic gynecomastia may take several months to years. 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. Reduction mammaplasty: The need for prospective randomized studies. The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability. 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. In this study the National Surgical Quality Improvement Program data set was queried for the Current Procedural Terminology code 19318 from the years 2005 to 2010, with principal outcome measurements of wound complications, surgical site infections, and reoperations. Follow-up ranged from 2 months to 3 years. What are Aetna breast reduction requirements? - RealSelf.com Fagerlund A, Lewin R, Rufolo G, et al. cursor: pointer; The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. 1998;41(3):240-245. The mean age was 42.8 years (SD 19.5 years). These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. Risk of bias was assessed independently by 2review authors. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. Oncoplastic reduction mammoplasty for breast cancer in women with macromastia: Oncological long-term outcomes. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. 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). 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. The operation was successfully performed in all 20 patients with a mean operating time of 51 mins and a hospital stay of 4 days. 2009;7(2):114-119. Breast Reduction Surgery and Gynecomastia Surgery - Medical - Aetna 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. 1993;17(3):211-223. color: blue Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. 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. In the case of breast reduction, however, for insurance purposes, it . A cohort study of breast cancer risk in breast reduction patients. Gynecomastia: A systematic review. Plast Reconstr Surg. Macromastia: all . Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: A review. 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. Petty PM, Solomon M, Buchel EW, Tran NV. 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 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. Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. This may lead to additional scarring and additional operating time. 2001;107(5):1234-1240. Surgical implications of obesity. They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. 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). 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. For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. Mizgala CL, MacKenzie KM. Variations in pattern of pubertal changes in girls. list-style-type: lower-alpha; of the following criteria must be met: Reduction mammaplasty: A review of managed care medical policy coverage criteria. Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammaplasty. Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne Surgery. OL LI { This conclusion is based primarily upon the Breast Reduction Assessment of Value and Outcomes (BRAVO) study, which is described in several articles (Kerrigan et al, 2001; Kerrigan et al, 2002; Collins et al, 2002). Prostate Cancer Prostatic Dis. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. ER expression did not correlate with the right (p = 0.51) and left 2D: 4D (p = 0.97). 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: 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. Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. OL OL OL LI { Until now, most published research on the subject has focused on how effective surgical treatment is on correcting the cosmetic appearance of the breast. Washington, DC: ACOG; 2011:121-122. 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. Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. color: red Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. list-style-type: decimal; padding-bottom: 4px; The authors of the BRAVO study reached several conclusions about reduction mammoplasty, most notably that breast size or the amount of breast tissue removed does not have any relationship to the outcome of breast reduction surgery (Kerrigan et al, 2002; Collins et al, 2002). 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. PDF Summary of Proposed Aetna Medicare Advantage Agreement 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). 1994;21(3):539-543. Although the BRAVO study nominally included a "control group", there was no comparison group of subjects selected from the same cohort, who were randomized or otherwise appropriately assigned to reduce bias, and treated with conservative management according to a protocol to ensure optimal conservative care. These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). Marshall WA, Tanner JM. The median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. color: white; Harmonic scalpel versus electrocautery in breast reduction surgery: A randomized controlled trial. ASPS clinical practice guideline summary on reduction mammaplasty. border-radius: 4px; Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Scand J Plast Reconstr Hand Surg. 40 . Women's Health and Cancer Rights Act of 1998. 1996;20(5):391-397. 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. # color: white; Guidelines for Adolescent Health Care. Plast Reconstr Surg. In these cases, breast reduction for men may take 2 to 3 hours. Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. /* aetna.com standards styles for templates */ These investigators stated that in an era of evidence-based medicine, surgeons performing breast reductions must adopt the results from scientific research into their clinical practice. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. In a systematic review, these investigators examined the role of radiotherapy in this context. Plast Reconstr Surg. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. 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. Ann Plast Surg. Mental health care professionals may be consulted to address psychological distress from gynecomastia. 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. PLoS One. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). Plast Reconstr Surg. 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. Laituri CA, Garey CL, Ostlie DJ, et al. Ann Plast Surg. Aesthetic Plast Surg. He Q, Zheng L, Zhuang D, et al. skin should not be excised horizontally below the inframammary fold. The requirement for coverage is that the amount of breast tissue to be removed has to be enough to improve your symptoms or function. Endocrinol Metab Clin North Am. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia.