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. This trial included all male patients who presented to the authors breast clinic who were diagnosed with primary gynecomastia, and were treated with a trial of tamoxifen 10 mg daily therapy, over a 10-year period from October 2004 to October 2015. Many men with breast enlargement are found to have pseudo-gynecomastia. 2015;49(6):311-318. li.bullet { Grooving where the bra straps sit on the shoulder. border-width:0; Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. 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 Surgery. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. Setala L, Papp A, Joukainen S, et al. Please check your insurance policy to see whether breast reduction is a covered procedure. Plastic Reconstruct Surg. Analysis was on an intention-to-treat basis. Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). 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]. Med Decis Making. border-radius: 4px; 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). Wound drainage after plastic and reconstructive surgery of the breast. No new trials were identified for this first update. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. color: blue 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). Plast Reconstr Surg. A detailed physical examination, including testicular examination. } 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. Policy Statement 6d: Aesthetic surgery procedures. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; 2009;19(3):e85-e90. Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. 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). Mizgala CL, MacKenzie KM. Hoyos AE, Perez ME, Dominguez-Millan R, et al. What can I do if my insurance denies coverage for breast reduction? Plastic Reconstr Surg. list-style-type: decimal; Reduction mammaplasty: Defining medical necessity. text-decoration: underline; .newText { Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. Determinants of surgical site infection after breast surgery. Exposure to partners using estrogen containing vaginal creams; Cancer chemotherapy (alkylating agents, methotrexate, vinca alkaloids, imatinib, combination chemotherapy), Androgen receptor blockers - bicalutamide, 5 reductase inhibitors - finasteride, dutasteride, Angiotensin converting enzyme inhibitors (captopril, enalapril), Calcium channelblockers(diltiazem, nifedipine, verapamil), Anabolic steroids(e.g., in body builders). Mayo Clin Proc. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. Breast reduction surgery (also called reduction mammaplasty) is a type of invasive procedure that involves incisions (cuts) in your skin to decrease the size and weight of your breasts . Breast Reduction | American Society of Plastic Surgeons The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability. Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. Management of gestational gigantomastia. 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). Fagerlund A, Lewin R, Rufolo G, et al. Collins ED, Kerrigan CL, Kim M, et al. Mannu GS, Sudul M, Bettencourt-Silva JH, et al. list-style-type: upper-roman; Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. A total of 182 thirty-day postoperative surgical complications were documented, but stratifying patients into 2 age groups did not reveal an association between age and any surgical complication (P = .26). 1. Women's Health and Cancer Rights Act of 1998. Fischer et al (2014a) evaluated predictors of postoperative complications following reduction mammoplasty using the NSQIP) data sets. Arlington Heights, IL: ASPS; May 2011. Handschin AE, Bietry D, Hsler R, et al. Aesthetic Plast Surg. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Breast Pump & Breastfeeding Insurance Coverage & Resources | Aetna Sixteen (23%) patients had complications and higher resection weight, increased BMI, and older age were found to have statistically significant complication rates with p-values of p<0.001, p=0.034, and p=0.004, respectively.The investigators also found that the incidence of complications was highest among current smokers and lowest among those who had never smoked with a 37% difference in the occurrence of complication (p<0.01). Safran T, Abi-Rafeh J, Alabdulkarim A, et al. There were only 2 studies of a total 25 patients that were considered as good in quality. The health burden of breast hypertrophy. These investigators retrospectively examined 83 patients with gynecomastia between January 2015 and December 2019. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. The goals of the surgery are to relieve symptoms caused by heavy breasts, to create a natural, balanced appearance with normal location of the nipple and areola, to maintain the capacity for lactation and allow for future breast exams/mammograms with minimal scarring or decreased sensation. 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. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. Aesthet Surg J. Laituri CA, Garey CL, Ostlie DJ, et al. display: none; breast augmentation with implant. OL OL OL OL LI { } Gynecomastia. and areola. The investigators found little difference between obese and non-obese women concerning patient's reports of resolution of symptoms and improvement in body image. 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. Follow-up ranged from 2 months to 3 years. 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. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . 2015;75(4):370-375. Variations in pattern of pubertal changes in girls. 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. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. cursor: pointer; Plast Reconstr Surg. 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). They investigated effects of age on 30-day surgical outcomes for reduction mammoplasty with a goal of improving patient care, counseling, and risk stratification on 3537 patients. 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. Early complications were rare (6.1%), with superficial skin and soft tissue infections accounting for 45.8% of complications. of . } Breast cancer found at the time of breast reduction. ASPS Recommended Coverage Criteria for Third Party Payors. 2019;8(4):431-440. Br J Plast Surg. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. 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 . 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). Criteria for reduction mammoplasty surgery from the American Society of Plastic Surgeons (ASPS, 2002; ASPS, 2011) states, among other things, that breast weight or breast volume is not a legitimate criterion upon which to distinguish cosmetic from functional indications. Tang CL, Brown MH, Levine R, et al. American Society of Plastic Surgeons (ASPS). border: none; Breast Concerns of Adolescents. Surgical treatment of gynecomastia: Complications and outcomes. 2007;356(5):479-485. The median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. A cohort study of breast cancer risk in breast reduction patients. # color: white; The majority (87.7 %) of cases presented with accompanying mastalgia. Gynecomastia surgery is the surgical correction of over-developed or enlarged breasts in men. Alternatively, you may qualify if your breast size causes significant symptoms, such as: Long-term neck, shoulder or neck pain. PDF Breast Reduction Surgery and Gynecomastia Surgery - Aetna Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery group. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS). Several important points should be considered in evaluating these challenges to insurers' criteria for breast reduction surgery. list-style-type: decimal; Horm Res Paediatr. 1998;101(2):361-364. Hoyos and colleagues (2021) stated that male chest definition surgery and patients complaining of breast tissue over-growth have been increasing in recent decades. Well-designed clinical trials provide reliable information about the effectiveness of an intervention, and provide valid information about the characteristics of patients who would benefit from that intervention. margin-top: 38px; 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. Srinivasaiahet al (2014) stated that although reduction mammoplasty has been shown to benefit physical, physiological, and psycho-social health there are recognized complications. 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 operation was successfully performed in all 20 patients with a mean operating time of 51 mins and a hospital stay of 4 days. PDF A look at new changes coming to E&M and breast coding in 2021 Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain. 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.. Plast Reconstr Surg. In the case of breast reduction, however, for insurance purposes, it . PDF Breast Reduction Surgery - Commercial Medical Policy - UHCprovider.com Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia. 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. Last Review01/04/2023. outline: none; Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. 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. All patients underwent routine investigations to exclude secondary causes of gynecomastia. In a survey of managed care policies regarding breast reduction surgery, Krieger and colleagues reported (2001)found that mostof the respondentsstated that they use weight of excised tissue as the main criterion for allowing the procedure, with anaverage cut-off value of 472 grams for a typicalwoman. A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. } 1999;103(6):1687-1690. In other patients, excess skin and nipple and areola relocation are necessary. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). The end-point was the complete resolution of gynecomastia. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. Breast J. 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. 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. 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. Management of gynecomastia should include evaluation, including laboratory testing, to identify underlying etiologies. color: red!important; 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. 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: padding-right: 18px; 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. Mistry RM, MacLennan SE, Hall-Findlay EJ. Statistical analysis was performed with student t-test and chi-square test. J Plast Surg Hand Surg. Breast reduction outcome study. Breast pumps. Aetna has their own sliding scale which requires more from smaller patients relative to the Schnur scale, but maxes out at 1000 gms per breast. Howrigan P. Reduction and augmentation mammoplasty. .strikeThrough { American Society of Plastic and Reconstructive Surgery (ASPRS). Philadelphia, PA: WB Saunders Company; 2008; Ch 73. 18th ed. 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. Reduction mammoplasty for asymptomatic members is considered cosmetic. Coding Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. z-index: 99; 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. Schnur PL, Schnur DP, Petty PM, et al. 2014b;30(6):641-647. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. This may lead to additional scarring and additional operating time. Prostate Cancer Prostatic Dis. Redundant skin was observed in 1 patient at 1 month post-operatively, whose breast, defined as grade-III, was the largest before operation. Bland KI, Copeland EM, eds. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. of the following criteria must be met: Arlington Heights, IL: ASPS; 2011. 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. For individuals who received radiation treatment to the chest . Scand J Plast Reconstr Hand Surg. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. 2020 Sep 4 [Online ahead of print]. Until now, most published research on the subject has focused on how effective surgical treatment is on correcting the cosmetic appearance of the breast. 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. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. Choban PS, Heckler R, Burge JC, Flancbaum L. Increased incidence of nosocomial infections in obese surgical patients. Little is known about the effect of surgical treatment on the psychological aspects of the disease. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Brown DM, Young VL. J Plast Reconstr Aesthet Surg. These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). Hello! He Q, Zheng L, Zhuang D, et al. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). Can objective predictors for operative success be identified? Marshall WA, Tanner JM. 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. Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. There were no restrictions on the basis of date or language of publication. 2017;35:157-161. Reduction mammoplasty: Criteria for insurance coverage. Type II gynecomastia is more generalized breast enlargement. 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. } Ann Plast Surg. } How to make Aetna pay for your breast reduction surgery Macromastia: all . 2011;128(4):243e-249e. Schnur subsequently refuted the validity of the Schnursliding scaleand stated that thescale should no longer be used as a criterion for the determination of insurance coverage for breast reduction surgery (Nguyen et al, 1999). 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. 1998;26(1):61-65. Devalia HL, Layer GT. Subjects were compared to age-matched norms from another study cohort. A total of 2779 patients were identified with a mean age of 42.7 (14.1) years and BMI of 31.6 (7.0) kg/m. Plastic Reconstr Surg. 2014;20(3):274-278. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. 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).
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