aetna breast reduction requirements

Reduction mammaplasty: An outcome study. Collins ED, Kerrigan CL, Kim M, et al. Petty PM, Solomon M, Buchel EW, Tran NV. 2006;9(2):109-114. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. 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. The authors (Nguyen et al, 2004) argue, based primarily on the results of the ASPS-funded BRAVO study (described below), that (with a single exception) no objective criteria for breast reduction surgery are supportable, including criteria based upon the presence of particular signs or symptoms, requirements based upon breast size or the amount of breast tissue removed, any minimum age limitations, any limitation based upon maximum body weight, requirements for a trial of conservative therapy, or the exclusion of certain procedures (liposuction). Risk of bias was assessed independently by 2review authors. Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. Ann Plastic Surg. 1997;100(4):875-883. The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. In fact, according to the American Society of Plastic Surgeons, more than 46,000 breast reduction procedures were performed in 2019, a six percent increase compared to 2018; but in recent years, insurance companies have become more likely to deny coverage for this medically recommended procedure. 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. A population-level analysis of bilateral breast reduction: does age affect early complications? 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. CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. right: 30px; 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 . Breast J. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. 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 Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . Quality of life after breast reduction. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. 2014;20(3):274-278. 1998;101(2):361-364. background-color: #cc0066; Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). 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). color: #FFF; Bertin ML, Crowe J, Gordon SM. 2014b;48(5):334-339. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. 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). J Laparoendosc Adv Surg Tech A. Ann Plast Surg. --> Follow-up ranged from 2 months to 3 years. 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. 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: 2010;125(5):1301-1308. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. Variations in pattern of pubertal changes in girls. Patients with abnormal histopathology could not be pre-operatively identified based on demographics. margin-bottom: 38px; Ann Plast Surg. 2009;62(2):195-199. Srinivasaiah N, Iwuchukwu OC, Stanley PR, et al. Several of the included studies reported improvement in QOL and several psychological domains after surgical treatment for gynecomastia. Brown MH, Weinberg M, Chong N, et al. 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. A detailed drug history, including list of medications, an assessment of indirect or environmental exposure to estrogenic compounds, and recreational drug use. Gland Surg. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. border-width:0; These preliminary findings need to be validated by well-designed studies. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. It was also found that only 3 % of subjects reported that they had no aesthetic motivation for surgery. First, the opinions and guidelines of medical professional organizations and consensus groups are considered according to the quality of the scientific evidence and supporting rationale. Schnur PL, Schnur DP, Petty PM, et al. Among these domains were: vitality, emotional discomfort, limitations due to physical aspects and limitations due to pain. In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. 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). The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. Please check your insurance policy to see whether breast reduction is a covered procedure. 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. 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). Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. J Plast Reconstr Aesthet Surg. Breast reduction surgery, also known as reduction mammaplasty, removes fat, breast tissue and skin from the breasts. Choban PS, Heckler R, Burge JC, Flancbaum L. Increased incidence of nosocomial infections in obese surgical patients. Tang CL, Brown MH, Levine R, et al. Oncoplastic reduction mammoplasty for breast cancer in women with macromastia: Oncological long-term outcomes. 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. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). } Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. Policy Statement 6d: Aesthetic surgery procedures. Plastic Reconstr Surg. Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . 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 Current concepts in gynaecomastia. American Society of Plastic Surgeons (ASPS). Breast J. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. 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. Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. 2008;53(3):255-261. list-style-type: upper-roman; ASPS clinical practice guideline summary on reduction mammaplasty. Plastic Reconstruct Surg. 2005;58(3):286-289. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. Plast Reconstr Surg. ul.ur li{ Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. 2013;71(5):471-475. 2001;108(1):62-67. J Plast Surg Hand Surg. 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. To get insurance coverage, you'll probably need . Qu and colleagues (2020) examined the effectiveness of vacuum-assisted breast biopsy systems for the treatment of gynecomastia. hr.separator { Chadbourne EB, Zhang S, Gordon MJ, et al. Aesthet Plastic Surg. Reduction mammaplasty. Gland Surg. Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance). Three review authors undertook independent screening of the search results. A systematic search of the published literature was performed. 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. Links to various non-Aetna sites are provided for your convenience only. 1997;185(6):593-603. Until now, most published research on the subject has focused on how effective surgical treatment is on correcting the cosmetic appearance of the breast. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. 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. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. background-color: #663399; Araco A, Gravante G, Araco F, et al. World J Surg. Miller AP, Zacher JB, Berggren RB, et al. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. 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.

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