aetna breast reduction requirements aetna breast reduction requirements

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. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. 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. 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. Recommended criteria for insurance coverage of reduction mammoplasty. 2011;128(4):243e-249e. list-style-type: upper-roman; Breast Reduction Surgery: Procedure, Recovery, Cost, and More - Healthline Breast Reduction Surgery and Gynecomastia Surgery - Medical - Aetna Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. } Breast cancer found at the time of breast reduction. font-size: 18px; list-style-type: upper-alpha; PLoS One. OL LI { 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. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. Three review authors undertook independent screening of the search results. 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). Gland Surg. } border: none; Orthopedic or spine surgeon evaluation of spinal pain; Radiotherapy (for the prevention or management of gynecomastia recurrence); Vacuum-assisted breast biopsy system for treament of gynecomastia. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. In the case of breast reduction, however, for insurance purposes, it . These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). Surgical treatment is indicated when medical treatments fail. } This may lead to additional scarring and additional operating time. Qu S, Zhang W, Li S, et al. ER expression did not correlate with the right (p = 0.51) and left 2D: 4D (p = 0.97). .strikeThrough { 2021;74(11):3128-3140. @media print { display: none; 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. Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass 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. Ann Plast Surg. The characteristics of patients as well as the curative effects between the 2 groups were analyzed. Kasielska-Trojan A, Danilewicz M, Antoszewski B. Plast Reconstr Surg. 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). The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. No data were provided on loss to follow-up. 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. Surgical implications of obesity. Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. Yao Y, Yang Y, Liu J, et al. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). Gynecomastia in patients with prostate cancer: Update on treatment options. The end-point was the complete resolution of gynecomastia. I have recently met with my primary doctor after speaking to my insurance company (aetna) for months about getting a breast reduction. Administration of Benefits and Transition Responsibilities 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 . Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. Breast Reduction Surgery | Johns Hopkins Medicine Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. Measuring health state preferences in women with breast hypertrophy. Risk factors for complications following breast reduction: Results from a randomized control trial. Narula HS, Carlson HE. Brown DM, Young VL. 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 mean volume of tissue resected was 250 g (range of 22 to 758 g) from the right breast and 244 g (range of 15 to 705 g) from the left breast. Plast Reconstr Surg. Resolution of idiopathic gynecomastia may take several months to years. 2014;20(3):274-278. Gynecomastia: A systematic review. Gynecomastia has been classified into2 types. 2007;356(5):479-485. 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. PDF 0185 Breast Reconstructive Surgery (1) - Aetna Other referencesto smaller studies published prior to the BRAVO study have been cited,examining symptoms before and after reduction mammoplasty; each of these studies suffer from limitations similar to those identified with the BRAVO study. Computed tomography scan of adrenal glands to identify adrenal lesions. Aetna considers molecular susceptibility testing for breast and/or epithelial ovarian cancer ("BRCA testing") medically necessary once per lifetime in any of the following categories of high-risk adults with breast or epithelial ovarian cancer (adapted from guidelines from the U.S. Preventive Services Task Force (for Brown MH, Weinberg M, Chong N, et al. Aesthetic Plast Surg. 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. Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: A review. There were no restrictions on the basis of date or language of publication. Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne 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. } In a review on Surgical treatment of primary gynecomastia in children and adolescents, Fischer et al (2014b) concluded that surgical correction of gynecomastia remains a purely elective intervention. After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. J Plast Reconstr Aesthet Surg. 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. Does Health Insurance Cover Breast Reduction Surgery? - GoodRx Tang CL, Brown MH, Levine R, et al. Schnur PL, Hoehn JG, Ilstrup DM, et al. 1990;24(1):61-67. 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. They concluded that higher resection weight, increased BMI, older age, and smoking are risk factors for complication and that patients should therefore be adequately counseled about losing weight and stopping smoking. width: 100%; Reduction mammoplasty: Cosmetic or reconstructive procedure? 2012;69(5):510-515. World J Surg. The following procedures are considered experimental and investigational because there is insufficient evidence of itseffectiveness or itseffectiveness has not been established: Aetna considers breast reduction, surgical mastectomy or liposuction for gynecomastia, either unilateral or bilateral, a cosmetic surgical procedure. For individuals who received radiation treatment to the chest . 1999;103(6):1674-1681. How to Get Your Breast Reduction Covered By Insurance - RealSelf News PDF Clinical Policy Bulletin: Cosmetic Surgery - Aetna A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. Scand J Plast Reconstr Hand Surg. See Appendix for Table 1. Plast Reconstr Surg. Last Review01/04/2023. Oxford, UK: National Health Service (NHS); October 2008. Often times, insurance company will dictate how much breast tissue to be removed. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. Flancbaum L, Choban PS. Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. Surgical treatment of gynecomastia: Complications and outcomes. background-color: #cc0066; Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. list-style-type: decimal; 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. 1995;95(6):1029-1032. 2000;106(5):991-997. Plast Reconstr Surg. The requirement for coverage is that the amount of breast tissue to be removed has to be enough to improve your symptoms or function. Refer to the member's specific plan document for applicable coverage. 2014a;34(1):66-73. A total of 90 patients underwent breast re-reduction surgery. 2003;111(2):688-694. 1991;27(3):232-237. Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. Sugrue CM, McInerney N, Joyce CW, et al. The median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. and areola. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. Devalia HL, Layer GT. 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. Breast reduction outcome study. Aetna considers breast reconstructive surgery to correct 1995;34(2):113-116. Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). All patients underwent routine investigations to exclude secondary causes of gynecomastia. 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. 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). 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. background-color:#eee; Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. A total of 15 articles met the inclusion criteria for review. Reduction mammoplasty for macromastia. 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. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). 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). 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. 2001;108(6):1591-1599. Petty PM, Solomon M, Buchel EW, Tran NV. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. Several important points should be considered in evaluating these challenges to insurers' criteria for breast reduction surgery. Prostate Cancer Prostatic Dis. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Kerrigan CL, Collins ED, Kim HM, et al. Ann Plast Surg. Plastic Reconstr Surg. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. #backTop:hover { 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. Special Clinical Concerns. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. Hoyos AE, Perez ME, Dominguez-Millan R, et al. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. 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. Among these domains were: vitality, emotional discomfort, limitations due to physical aspects and limitations due to pain. A systematic search of the published literature was performed. 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 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: When seeking preauthorization for a breast reduction, your goal is generally twofold. #closethis { .arrowPurpleSmall, a:hover.arrowPurpleSmall { 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). Fagerlund A, Lewin R, Rufolo G, et al. In a systematic review, these investigators examined the role of radiotherapy in this context. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. Fischer JP, Cleveland EC, Shang EK, et al. The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. Reduction mammaplasty provides long-term improvement in health status and quality of life. These investigators searched the literature on the treatment of Simon's grade I and II gynecomastia in PubMed, Scopus, Science Direct, and Cochrane using keywords "gynecomastia" and "liposuction". Plast Reconstr Surg. Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. 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 . (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) 2015;75(4):383-387. 0017 - Breast Reduction Surgery and Gynecomastia Surgery, are met. Also, there was no correlation between PR expression and 2D: 4D. J Plast Surg Hand Surg. Alternatively, you may qualify if your breast size causes significant symptoms, such as: Long-term neck, shoulder or neck pain. These preliminary findings need to be validated by well-designed studies. 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. Surgery. 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. Obstet Gynecol Clin North Am. Washington, DC: ACOG; 2011:121-122. Gynecomastia: Evolving paradigm of management and comparison of techniques. 2006;118(4):840-848. Please check your insurance policy to see whether breast reduction is a covered procedure. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. There were 18 out of 415 studies eligible to review. The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. Mistry RM, MacLennan SE, Hall-Findlay EJ. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. 2000;106(2):280-288. Patients undergoing surgery for gynecomastia should know that their scars may be visible when they are shirtless. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. Marshall WA, Tanner JM. 2007;36(2):497-519. What are Aetna breast reduction requirements? - RealSelf.com Treatment of adolescent gynecomastia. 1993;17(3):211-223. 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. Plastic Reconstruct Surg. 2001;108(1):62-67. Arlington Heights, IL: ASPS; March 9, 2002. Bertin ML, Crowe J, Gordon SM. Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. height:2px; cursor: pointer; While the efficacy of radiotherapy as a therapeutic modality for gynecomastia was also established, it was shown to be less effective than other available options. Plastic surgery for teenagers briefing paper. z-index: 99; 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). PDF Breast Reduction Surgery and Gynecomastia Surgery - Aetna J Plast Reconstr Aesthet Surg. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). 2015;49(6):311-318. top: 0px; The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. GP Notebook. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. Is breast reduction covered by health insurance? | ASPS No other operation-related complications were observed. Plast Reconstr Surg. The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. Well-designed, prospective, controlled clinical studies have not been performed to assess the effectiveness of surgical removal of modest amounts of breast tissue in reducing neck, shoulder, and back pain and related disability in women. Analysis was on an intention-to-treat basis. Ages ranged from 18 to 66 years. Bland KI, Copeland EM, eds. PDF Breast Reduction Surgery - Commercial Medical Policy - UHCprovider.com /* aetna.com standards styles for templates */ American Society of Plastic Surgeons (ASPS). Variations in pattern of pubertal changes in girls. OL OL OL LI { Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. Hello! If reduction mammoplasty was performed before oncological treatment, the incidence of abnormal findings was higher. Blomqvist L, Eriksson A, Brandberg Y. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). Seitchik MW. Fagerlund A, Cormio L, Palangi L, et al. breast augmentation with implant. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. 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. 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. Socioeconomic Committee Position Paper. Arlington Heights, IL: ASPRS; 1987. 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. Plast Reconstr Surg. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. 2019;8(4):431-440. 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. 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.. Many men with breast enlargement are found to have pseudo-gynecomastia. The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? 1999;103(6):1682-1686. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. There were no statistically significant differences between the 2 vacuum-assisted breast biopsy systems according to the mean age, the mean operation time, sites, or grade. 2002;109(5):1556-1566. Araco A, Gravante G, Araco F, et al. Type II gynecomastia is more generalized breast enlargement. 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.