aetna breast reduction requirements

Level of Evidence = IV. Narula HS, Carlson HE. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. 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. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. Coding Flancbaum L, Choban PS. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. breast augmentation with implant. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. 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. Cochrane Database Syst Rev. Evidence-based clinical practice guideline: Reduction mammaplasty. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. 2008;121(4):1092-1100. Ages ranged from 18 to 66 years. 2019;8(4):431-440. } Aesthet Surg J. 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. # font-weight: bold; 2015;49(6):311-318. 0017 - Breast Reduction Surgery and Gynecomastia Surgery, are met. Autorino R, Perdona S, D'Armiento M, et al. 2015;10(8):e0136094. #closethis { 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. Plast Reconstr Surg. 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). 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). list-style-type : square !important; Ann Plast Surg. Surgical implications of obesity. padding: 15px; Fischer et al (2014a) evaluated predictors of postoperative complications following reduction mammoplasty using the NSQIP) data sets. text-decoration: underline; Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. No new trials were identified for this first update. In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. Jones SA, Bain JR. Review of data describing outcomes that are used to assess changes in quality of life after reduction mammaplasty. For example, at a body surface area of 1.5m, Aetna requires a minimum weight of 385 grams removed from each breast, whereas the Schnur scale would only require 260g. 2001;76(5):503-510. 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. Level of Evidence = IV. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. Collins ED, Kerrigan CL, Kim M, et al. Quality of life after breast reduction. Copyright Aetna Inc. All rights reserved. No data were provided on loss to follow-up. Each surgeon who participated in the study reported on the height, weight, and volume of reduction of their last 15 to 20 patients, and each surgeon provided their intuitive sense regarding the motivation of each patient for breast reduction surgery. The investigators found little difference between obese and non-obese women concerning patient's reports of resolution of symptoms and improvement in body image. Hello! This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. Plastic Reconstr Surg. Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. The 2 vacuum-assisted breast biopsy systems (Mammotome and Encor) were used for the patients with gynecomastia. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. Breast asymmetries: A brief review and our experience. Plast Reconstr Surg. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. 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. 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. Can objective predictors for operative success be identified? Breast reduction for symptomatic macromastia. Healing balms, scented soaps, skin lotions, shampoos and styling gels containing lavender oilor tea tree oil. Most UnitedHealthcare plans have a specific exclusion for breast reduction surgery except as required by the . The operative group in the BRAVO study was drawn from a number of surgical practices that volunteered to participate in the study; no details are provided about how each center selected candidates for reduction mammoplasty, or how they chose patients who underwent mammoplasty for inclusion in the study. Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. .fixedHeaderWrap { 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. 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 Med Decis Making. 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". Burns JL, Blackwell SJ. Treating providers are solely responsible for medical advice and treatment of members. Reduction mammoplasty improves symptoms of macromastia. border: none; 2014a;34(3):409-416. 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). Ann Plast Surg. Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. 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:. Refer to the member's specific plan document for applicable coverage. 2008;61(5):493-502. These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). 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. 1995;95(6):1029-1032. Khan SM, Smeulders MJ, Van der Horst CM. 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. 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). Ann Plast Surg. 1994;21(3):539-543. 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). 2 . Am J Infect Control. display: block; skin should not be excised horizontally below the inframammary fold. The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. Determinants of surgical site infection after breast surgery. color: red } 2005;58(3):286-289. 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. The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. Plastic Reconstruct Surg. 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. The following factors were independently associated with any surgical complications: morbid obesity (odds ratio [OR], 2.1; P < .001), active smoking (OR, 1.7; P < .001), history of dyspnea (OR, 2.0; P < .001), and resident participation (OR, 1.8; P = .01) while factors associated with major complications included active smoking (OR, 2.7; P < .001), dyspnea (OR, 2.6; P < .001), resident participation (OR, 2.1; P < .001), and inpatient surgery (OR, 1.8; P = .01). Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. Blomqvist L, Eriksson A, Brandberg Y. 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). 2014;20(3):274-278. A systematic search of the published literature was performed. Arlington Heights, IL: ASPRS; 1987. } Risk factors for complications following breast reduction: Results from a randomized control trial. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. Handschin AE, Bietry D, Hsler R, et al. background-color: #cc0066; 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. The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. of . For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. 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. 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. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . A total of 81 patients were included in this study. position: fixed; Reduction mammoplasty is among the most commonly performed cosmetic procedures in the United States. No author listed. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. Plast Reconstr Surg. 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. Sugrue CM, McInerney N, Joyce CW, et al. Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. Schnur PL, Hoehn JG, Ilstrup DM, et al. 2010;125(5):1301-1308. Variations in pattern of pubertal changes in girls. 2000;45(6):575-580. Three review authors undertook independent screening of the search results. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. A total of 3 RCTs were identified and included in the review out of 190 studies that were initially screened; all evaluated wound drainage after breast reduction surgery. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . A total of 90 patients underwent breast re-reduction surgery. However, these medications should be reserved for those with no decrease in breast size after 2 years. Gonzalez FG, Walton RL, Shafer B, et al. 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. 2020 Sep 4 [Online ahead of print]. Ann Plast Surg. list-style-type: lower-alpha; Grooving where the bra straps sit on the shoulder.

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