aetna breast reduction requirements aetna breast reduction requirements

PDF Gender Dysphoria Treatment - Cigna Some individuals, however, have argued that reduction mammoplasty may be indicated in any woman who suffers from back and shoulder pain, regardless of how small her breasts are or how little tissue is to be removed (ASPS, 2002). Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Redundant skin was observed in 1 patient at 1 month post-operatively, whose breast, defined as grade-III, was the largest before operation. Gynecomastia in patients with prostate cancer: A systematic review. 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. 2000;106(2):280-288. Gynecomastia: A systematic review. 1994;21(3):539-543. Breast asymmetries: A brief review and our experience. 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. Early complications were rare (6.1%), with superficial skin and soft tissue infections accounting for 45.8% of complications. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. 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. Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. 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. He Q, Zheng L, Zhuang D, et al. 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. position: fixed; 2015;(10):CD007258. 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 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). Breast reduction outcome study. The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. 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. Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammaplasty. Refer to the member's specific plan document for applicable coverage. Saunders Co.; 1991. Abnormalities in Adolescent Breast Development. PDF Procedures, programs and drugs you must precertify - AmeriBen Khan SM, Smeulders MJ, Van der Horst CM. Follow-up ranged from 2 months to 3 years. Prostate Cancer Prostatic Dis. Marshall WA, Tanner JM. In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. In the case of breast reduction, however, for insurance purposes, it . } Breast Reconstructive Surgery - Medical Clinical Policy Bulletins - Aetna PDF 0185 Breast Reconstructive Surgery (1) - Aetna The authors recruited 67 consecutive female patients who underwent inferior pedicle reduction mammoplasty in order to determine the effects of resection weight, BMI, age, and smoking on complication rates following reduction mammoplasty. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. Leclere FM, Spies M, Gohritz A, Vogt PM. Reduction mammaplasty: A review of managed care medical policy coverage criteria. There were no restrictions on the basis of date or language of publication. Kerrigan CL, Collins ED, Kneeland TS, et al. Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. .newText { Plastic Reconstruct Surg. OL OL OL OL OL LI { The average interval between primary and secondary surgery was 14 years (range of 0 to 42 years). 1997;185(6):593-603. Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance). They also analyzed if timing of reduction mammoplasty in relation to oncological treatment influenced the incidence of abnormal findings, and compared if patients with abnormal contralateral histopathology differed from the study population in terms of demographics. To get insurance coverage, you'll probably need . 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. 2002;109(5):1556-1566. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. Reduction mammaplasty: The need for prospective randomized studies. If reduction mammoplasty was performed before oncological treatment, the incidence of abnormal findings was higher. Raispis T, Zehring RD, Downey DL. Plast Reconstr Surg. 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. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. 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. Kasielska-Trojan A, Danilewicz M, Antoszewski B. #backTop { margin-bottom: 38px; With the majority of BBRs performed as an inpatient procedure, there was a trend towards less drain usage in surgeons performing this procedure as an out-patient; however, this was not statistically significant (p = 0.07). Fischer et al (2014a) evaluated predictors of postoperative complications following reduction mammoplasty using the NSQIP) data sets. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass 2001;108(1):62-67. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. In a systematic review, these investigators examined the role of radiotherapy in this context. 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. Nelson et al (2014a) analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Howrigan P. Reduction and augmentation mammoplasty. Statistical analysis was performed with student t-test and chi-square test. 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. Ann Plast Surg. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. 2015;49(6):363-366. 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. 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. 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. Variations in pattern of pubertal changes in girls. Reduction mammaplasty: An outcome study. Gynecomastia. 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.. Reduction mammaplasty provides long-term improvement in health status and quality of life. Annu Rev Med. } Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. Reduction mammoplasty: Cosmetic or reconstructive procedure? Plast Reconstr Surg. Bertin ML, Crowe J, Gordon SM. Level of Evidence = IV. Plast Reconstr Surg. American Society of Plastic Surgeons (ASPS). padding-right: 18px; The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. Plastic Reconstr Surg. Arlington Heights, IL: ASPS; May 2011. Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. 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 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. Cochrane Database Syst Rev. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. You may be able to buy a breast pump and supplies from one of our medical equipment suppliers at no charge or at a discounted rate. } list-style-type : square !important; Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. z-index: 99; Because reduction mammoplasty may be used for both medically necessary and cosmetic indications, Aetna has set forth above objective criteria to distinguish medically necessary reduction mammoplasty from cosmetic reduction mammoplasty. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). Results illustrated that 3050 patients were <60 years of age (39.7 11.8 years) and 487 were 60 years of age (65.1 4.7 years). Please check your insurance policy to see whether breast reduction is a covered procedure. Breast reduction for symptomatic macromastia. OL OL OL LI { color: blue Principles of breast re-reduction: A reappraisal. For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. 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. Aesthetic Plast Surg. Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. PDF Breast Reduction Surgery - Commercial Medical Policy - UHCprovider.com The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. Aesthet Surg J. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). Breast cancer found at the time of breast reduction. Patients with abnormal histopathology could not be pre-operatively identified based on demographics. Choban PS, Heckler R, Burge JC, Flancbaum L. Increased incidence of nosocomial infections in obese surgical patients. 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. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. Mayo Clin Proc. 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. See Appendix for Table 1. Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. In a within-patient, randomized, patient- and assessor-blinded, controlled study, Anzarut et al (2007) evaluated the use of completely autologous platelet gel in 111 patients undergoing bilateral reduction mammoplasty to reduce post-operative wound drainage. The authors reach the remarkable conclusion that a woman with normal sized breasts who has only a few ounces of breast tissue removed is as likely to receive as much benefit from breast reduction surgery as a women with large breasts who has substantially more breast tissue removed. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. Tang CL, Brown MH, Levine R, et al. Am J Infect Control. 1998;49:215-234. Ann Plastic Surg. Handschin AE, Bietry D, Hsler R, et al. Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. The characteristics of patients as well as the curative effects between the 2 groups were analyzed. 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. Obesity and complications in breast reduction surgery: Are restrictions justified? Another set of breast pump supplies if you get pregnant . A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. Level of Evidence = III. 2nd ed. A total of 244 out of 1,628 patients with the average age of 23.13 years. 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. 2017;139(6):1313-1322. A detailed physical examination, including testicular examination. background: #5e9732; Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. Ann Plast Surg. In a Cochrane review, Khan and colleagues (2015) stated that wound drains are often used after plastic and reconstructive surgery of the breast in order to reduce potential complications. Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. Disproportionately large breasts can cause both physical and emotional . Arch Dis Child. Reduction mammoplasty also known as breast reduction surgery, is a surgical procedure in women to reduce the weight, mass, and size of the breast. breast augmentation with implant. Townsend: Sabiston Textbook of Surgery. color: #FFF; Philadelphia, PA: W.B. Burns JL, Blackwell SJ. 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. 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. OL LI { Aesthet Plastic Surg. Reduction mammaplasty: Defining medical necessity. Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. Kalliainen LK; ASPS Health Policy Committee. Plastic Reconstr Surg. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. A total of 81 patients were included in this study. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. 2014;20(3):274-278. Narula HS, Carlson HE. Patient demographics, surgical technique, and outcomes were analyzed. Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. Furthermore, you must test negative for breast cancer on a mammogram a maximum of two years before your surgery if you are 50 or older. Gynecomastia is a very common concern of male adolescence. J Plast Surg Hand Surg. Plast Reconstr Surg. 2016;20(3):256-260. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. There were 18 out of 415 studies eligible to review. These preliminary findings need to be validated by well-designed studies. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. A total of 90 patients underwent breast re-reduction surgery. border: none; American Society of Plastic Surgeons (ASPS). Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) Plast Reconstr Surg. .fixedHeaderWrap { Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. list-style-type: upper-roman; The primary outcome was the difference in wound drainage over 24 hours. 2018;24(6):1043-1045. Schnur PL, Hoehn JG, Ilstrup DM, et al. Plast Reconstr Surg. The authors concluded that gynecomastia treatment combining high-definition liposculpture to male breast tissue resection via a new, almost invisible incision allowed these researchers to achieve an athletic and natural appearance of the male pectoral area with a very low rate of complications. 1998;101(2):361-364. J Laparoendosc Adv Surg Tech A. No data were provided on loss to follow-up. Does Aetna Cover Breast Reduction? | HelpAdvisor.com Determinants of surgical site infection after breast surgery. Horm Res Paediatr. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. Mental health care professionals may be consulted to address psychological distress from gynecomastia. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. 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:. Breast Concerns of Adolescents. Safran T, Abi-Rafeh J, Alabdulkarim A, et al. 2002;33:208-217. Petty PM, Solomon M, Buchel EW, Tran NV. In other patients, excess skin and nipple and areola relocation are necessary. } Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. What can I do if my insurance denies coverage for breast reduction? Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. Breast reduction surgery might also help improve self-image and the ability to take part in physical activities. list-style-type: decimal; 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. 1995;34(2):113-116. 1997;100(4):875-883. Qu S, Zhang W, Li S, et al. Insurers have commonly used the amount of breast tissue to be removed as a criterion for evaluating the medical necessity of breast reduction surgery. CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the Plast Reconstr Surg. Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. The investigators found that comorbid conditions increased across obesity classifications (p < 0.001), with significant differences noted in all cohort comparisons except when comparing class I to class II (p = 0.12). 2008;61(5):493-502. Ann Chir Plast Esthet. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. 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. Does Blue Cross Blue Shield Cover Breast Reduction Surgery? - HelpAdvisor Complication rates were inconsistent throughout the studies, ranging from 0.06 % to 26.67 %. 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%.