aetna breast reduction requirements aetna breast reduction requirements

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. 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). Alternatively, you may qualify if your breast size causes significant symptoms, such as: Long-term neck, shoulder or neck pain. Saunders Co.; 1991. Pain/discomfort/ulceration from bra straps cutting into shoulders; Skin breakdown (severe soft tissue infection, tissue necrosis, ulceration hemorrhage) from overlying breast tissue; There is a reasonable likelihood that the member's symptoms are primarily due to macromastia; Reduction mammoplasty (also spelled as 'mammaplasty') is likely to result in improvement of the chronic pain; Pain symptoms persist as documented by the physician despite at least a 3-month trial of therapeutic measures such as: Analgesic/non-steroidal anti-inflammatory drugs (NSAIDs) interventions and/or muscle relaxants, Dermatologic therapy of ulcers, necrosis and refractory infection, Physical therapy/exercises/posturing maneuvers, Supportive devices (e.g., proper bra support, wide bra straps), Chiropractic care or osteopathic manipulative treatment. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. 2014a;34(3):409-416. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . In a systematic review, these investigators examined the role of radiotherapy in this context. Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. Kerrigan CL, Collins ED, Striplin D, et al. 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). Med Decis Making. top: 0px; 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 . 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. Mental health care professionals may be consulted to address psychological distress from gynecomastia. 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. Philadelphia, PA: W.B. 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). This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. } 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. Harmonic scalpel versus electrocautery in breast reduction surgery: A randomized controlled trial. Photographs were taken pre-operatively and 1, 3, 6, and 12 months post-operatively. --> Jones SA, Bain JR. Review of data describing outcomes that are used to assess changes in quality of life after reduction mammaplasty. Nelson et al (2014a) analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. American Society of Plastic and Reconstructive Surgery (ASPRS). Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. 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. Burdette TE, Kerrigan CL, Homa KA. Aetna considers breast reduction surgery medically necessary for non-cosmetic indications for women aged 18 or older or for whom growth is complete (i.e., breast size stable over one year) when any of the following criteria (A, B, or C) is met: Macromastia: all of the following criteria must be met: Breast reduction for symptomatic macromastia. The Mammotome procedure represented another novel therapeutic option for gynecomastia. Imahiyerobo TA, Pharmer LA, Swistel AJ, Talmor M. A comparative retrospective analysis of complications after oncoplastic breast reduction and breast reduction for benign macromastia: Are these procedures equally safe? Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. 2005;55(3):227-231. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. Most UnitedHealthcare plans have a specific exclusion for breast reduction surgery except as required by the . OL OL OL OL OL LI { Reduction mammoplasty also known as breast reduction surgery, is a surgical procedure in women to reduce the weight, mass, and size of the breast. Little is known about the effect of surgical treatment on the psychological aspects of the disease. Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? Aesthetic Plast Surg. There were no restrictions on the basis of date or language of publication. The health burden of breast hypertrophy. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. 2000;45(6):575-580. 2nd ed. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). In: Townsend CM, Beuchamp RD, Evers BM, eds. When seeking preauthorization for a breast reduction, your goal is generally twofold. The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. Handschin AE, Bietry D, Hsler R, et al. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. Aesthet Plastic Surg. 1994;21(3):539-543. This will be computed based on your body area. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). Coding Drainage in breast reduction surgery: A prospective randomised intra-patient trail. } J Am Coll Surg. ASPS Recommended Coverage Criteria for Third Party Payors. The average interval between primary and secondary surgery was 14 years (range of 0 to 42 years). Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. } Ann Chir Plast Esthet. font-size: 18px; Hoyos AE, Perez ME, Dominguez-Millan R, et al. The majority (87.7 %) of cases presented with accompanying mastalgia. 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. Grooving where the bra straps sit on the shoulder. } 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. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. However, these medications should be reserved for those with no decrease in breast size after 2 years. The risks included infection, wound breakdown, scarring, and the need for re-operating. Among these domains were: vitality, emotional discomfort, limitations due to physical aspects and limitations due to pain. Please check your insurance policy to see whether breast reduction is a covered procedure. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. 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. The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS). ol.numberedList LI { No necrosis, systemic infection, or muscle paralysis was reported. 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. 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. Several of the included studies reported improvement in QOL and several psychological domains after surgical treatment for gynecomastia. However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. 2014a;34(1):66-73. 1998;49:215-234. Oncoplastic reduction mammoplasty for breast cancer in women with macromastia: Oncological long-term outcomes. Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. Mannu GS, Sudul M, Bettencourt-Silva JH, et al. color: white; Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. 2017;35:157-161. Socioeconomic Committee Position Paper. Wound drainage after plastic and reconstructive surgery of the breast. A total of 90 patients underwent breast re-reduction surgery. list-style-type: lower-roman; Secondary outcomes included subjective as well as objective assessments of pain and wound healing. The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 %)]. Ages ranged from 18 to 66 years. Khan SM, Smeulders MJ, Van der Horst CM. } Plast Reconstr Surg. Subjects were compared to age-matched norms from another study cohort. The average age of the studied individuals was 25.7 years (SD = 7.8); ER and PR expression was detected in breasts, and digit ratios were calculated in patients with idiopathic gynecomastia. OL OL OL LI { GP Notebook. Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. Breast hypertrophy. 1993;17(3):211-223. Statistical analysis was performed with student t-test and chi-square test. Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. Thus, more than 1/3of operative subjects selected for inclusion in the study did not complete it; most of the operative subjects who did not complete the study were lost to follow-up. Srinivasaiahet al (2014) stated that although reduction mammoplasty has been shown to benefit physical, physiological, and psycho-social health there are recognized complications. 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. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. } Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability. 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. Washington, DC: ACOG; 2011:121-122. Management of gestational gigantomastia. Reduction mammoplasty improves symptoms of macromastia. They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. Srinivasaiah N, Iwuchukwu OC, Stanley PR, et al. 2015;75(4):383-387. 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. 1999;103(6):1682-1686. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Data were prospectively gathered on complications as a part of randomized control trial (RCT) examining psycho-socialand quality of life(QOL) benefits of reduction mammoplasty. Fischer S, Hirsch T, Hirche C, et al. 2006;9(2):109-114. Ann Plast Surg. 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. Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. There were 18 out of 415 studies eligible to review. Variations in pattern of pubertal changes in girls. 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). 1999;103(6):1674-1681. 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. Gynecomastia in patients with prostate cancer: Update on treatment options. Policy. Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. Aesthetic Plast Surg. Determinants of surgical site infection after breast surgery. Moreover, these researchers stated that further studies are needed within the common gynecomastia population managed by plastic surgeons to examine the clinical and economical utility of this intervention before a recommendation for its ubiquitous adoption in plastic surgery can be made to continue improving outcomes for high-risk gynecomastia patients. These investigators retrospectively examined 83 patients with gynecomastia between January 2015 and December 2019. Insurers have commonly used the amount of breast tissue to be removed as a criterion for evaluating the medical necessity of breast reduction surgery. Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. Aesthet Surg J. padding-right: 18px; The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. Breast Concerns of Adolescents. list-style-type: upper-alpha; Cochrane Database Syst Rev. ul.ur li{ A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Breast pumps. list-style-type: lower-alpha; Reduction mammaplasty: A review of managed care medical policy coverage criteria. 1997;185(6):593-603. For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. Reduction mammoplasty for macromastia. 2002;33:208-217. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. 2009;19(3):e85-e90. 1993;91(7):1270-1276. 1996;20(5):391-397. Surgery. Ann Plast Surg. Arlington Heights, IL: ASPS; May 2011. 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. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). Kalliainen LK; ASPS Health Policy Committee. Townsend: Sabiston Textbook of Surgery. Surg Laparosc Endosc Percutan Tech. 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:. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). Qu S, Zhang W, Li S, et al. Ann Plast Surg. The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. 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. Inclusion criteria were as follows: men diagnosed with gynecomastia and BMI of less than or equal to 32 kg/m2, adequate skin elasticity, and general good health. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. The characteristics of patients as well as the curative effects between the 2 groups were analyzed. Complication rates were inconsistent throughout the studies, ranging from 0.06 % to 26.67 %. The authors concluded that the vacuum-assisted breast biopsy system could be used as a feasible and minimally invasive approach for the treatment of gynecomastia. 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. li.bullet { Level of Evidence = IV. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. 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). 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). Three review authors undertook independent screening of the search results. display: block; outline: none; The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. Ann Plast Surg. 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.