aetna breast reduction requirements

Breast Reconstructive Surgery - Medical Clinical Policy Bulletins - Aetna Lonie S, Sachs R, Shen A, et al. A non-standardized survey showed a very high satisfaction index. 2008;53(3):255-261. CG-SURG-71 Reduction Mammaplasty - Anthem Aesthet Plastic Surg. Breast Reduction | American Society of Plastic Surgeons 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. } Burns JL, Blackwell SJ. Behmand RA, Tang DH, Smith DJ Jr. Outcomes in breast reduction surgery. Surgical treatment of gynecomastia: Complications and outcomes. Pediatr Surg Int. Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? Burdette TE, Kerrigan CL, Homa KA. background-color: #663399; Plast Reconstr Surg. He Q, Zheng L, Zhuang D, et al. li.bullet { Gynecomastia has been classified into2 types. Can objective predictors for operative success be identified? Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. Reduction mammoplasty is among the most commonly performed cosmetic procedures in the United States. Measuring health state preferences in women with breast hypertrophy. PDF Clinical Policy Bulletin: BRCA Testing, Prophylactic Mastectomy - Aetna Breast pumps. (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) 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. Coding } Mistry RM, MacLennan SE, Hall-Findlay EJ. I have recently met with my primary doctor after speaking to my insurance company (aetna) for months about getting a breast reduction. Analysis was on an intention-to-treat basis. 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. 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:. padding: 10px; It is not intuitively obvious, however, that breast weight would substantially contribute to back, neck and shoulder pain in women with normal or small breasts. 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. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. Kerrigan CL, Collins ED, Kneeland TS, et al. .strikeThrough { Ann Chir Plast Esthet. background-color:#eee; 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. padding: 15px; 1993;91(7):1270-1276. No necrosis, systemic infection, or muscle paralysis was reported. A population-level analysis of bilateral breast reduction: does age affect early complications? Level of Evidence = III. 1998;49:215-234. 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. background-color: #cc0066; of . height:2px; The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. Breast Reduction Surgery and Gynecomastia Surgery - Medical - Aetna There were no restrictions on the basis of date or language of publication. There were only 2 studies of a total 25 patients that were considered as good in quality. J Pediatr Surg. Aesthetic Plast Surg. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. Administration of Benefits and Transition Responsibilities 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. Links to various non-Aetna sites are provided for your convenience only. Plast Reconstr Surg. Oxfordshire NHS Trust. In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. Chadbourne EB, Zhang S, Gordon MJ, et al. Radiotherapy for prevention or management of gynecomastia recurrence: Future role for general gynecomastia patients in plastic surgery given current role in management of high-risk prostate cancer patients on anti-androgenic therapy. Hello! } For medical Nguyen JT, Wheatley MJ, Schnur PL, et al. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. 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). Leclere FM, Spies M, Gohritz A, Vogt PM. Fischer JP, Cleveland EC, Shang EK, et al. 1991;27(3):232-237. 2008;61(5):493-502. } 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. The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. 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. Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. 2002;33:208-217. 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. Gland Surg. Aesthetic Plast Surg. Ann Plast Surg. Aetna's Itty Bitty Titty Committee - by Libby Watson - Sick Note Breast reduction outcome study. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. Breast J. } 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). 2000;106(5):991-997. PDF A look at new changes coming to E&M and breast coding in 2021 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). Am Surg. list-style-type : square !important; Breast and aesthetic surgery. .newText { Handschin AE, Bietry D, Hsler R, et al. Breast reduction surgery is considered cosmetic for all indications not listed in section I, A. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. In: Townsend CM, Beuchamp RD, Evers BM, eds. Surgical implications of obesity. 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). Treating providers are solely responsible for medical advice and treatment of members. Breast Reduction Surgery: Procedure, Recovery, Cost, and More - Healthline However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. Principles of breast re-reduction: A reappraisal. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. 2nd ed. Recommended criteria for insurance coverage of reduction mammoplasty. Plast Reconstr Surg. Breast cancer found at the time of breast reduction. Kasielska-Trojan A, Danilewicz M, Antoszewski B. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. Srinivasaiahet al (2014) stated that although reduction mammoplasty has been shown to benefit physical, physiological, and psycho-social health there are recognized complications. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. 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. and areola. Cochrane Database Syst Rev. Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne 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. It's important to note that CPT 19324 - mammaplasty, augmentation without pros-thetic implant - has been deleted. PDF Gender Dysphoria Treatment - Cigna Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. 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. A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery. The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. These investigators stated that in an era of evidence-based medicine, surgeons performing breast reductions must adopt the results from scientific research into their clinical practice. Breast reduction, also known as reduction mammaplasty, is a procedure to remove excess breast fat, glandular tissue and skin to achieve a breast size more in proportion with your body and to alleviate the discomfort associated with excessively large breasts (macromastia). Surgical removal is rarely indicated and the vast majority of the time is for cosmetic reasons, as there is no functional impairment associated with this disorder. 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). Plast Reconstr Surg. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Surgical management of gynecomastia--a 10-year analysis. Redundant skin was observed in 1 patient at 1 month post-operatively, whose breast, defined as grade-III, was the largest before operation. Annu Rev Med. 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. 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. 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. The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. Healing balms, scented soaps, skin lotions, shampoos and styling gels containing lavender oilor tea tree oil. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. 2007;356(5):479-485. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. American Society of Plastic Surgeons (ASPS). 2001;108(1):62-67. Breast Reduction Surgery and Gynecomastia Surgery - Medical - Aetna 2012;130(4):785-789. The median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. Radiotherapy was shown to significantly reduce the incidence to a median of 23 %, with all 6 RCTs assessed demonstrating a statistically significant decrease in incidence following radiotherapy prophylaxis. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. Little is known about the effect of surgical treatment on the psychological aspects of the disease. 2009;7(2):114-119. ol.numberedList LI { Arlington Heights, IL: ASPS; May 2011. Refer to the member's specific plan document for applicable coverage. 2000;44(2):125-134. 2008;32(1):38-44. 2019;8(4):431-440. Br J Plast Surg. Socioeconomic Committee Position Paper. PDF Breast Reduction Surgery and Gynecomastia Surgery - Aetna 2013;71(5):471-475. Quality of life after breast reduction. 2016;20(3):256-260. Computed tomography scan of adrenal glands to identify adrenal lesions. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. 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. Sugrue CM, McInerney N, Joyce CW, et al. 2015;75(4):383-387. Marshall WA, Tanner JM. Is breast reduction covered by health insurance? | ASPS The authors specified the value of these study results was in the identification of morbid obesity as a significant predictor of overall morbidity and active smoking as a strong predictor of major surgical morbidity. Reduction mammoplasty improves symptoms of macromastia. Evidence-based clinical practice guideline: Reduction mammaplasty. Second, it is the burden of the proponent of an intervention to provide reliable evidence of its effectiveness, not the burden of ones whoquestion the effectivenessan intervention to provide definitive proof of ineffectiveness. The 2 vacuum-assisted breast biopsy systems (Mammotome and Encor) were used for the patients with gynecomastia. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. Schnur et al (1991) reported on a sliding scale assigns a weight of breast tissue to be removed based on body weight and surface area. } Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). He and associates (2011) examined the safety and feasibility of vacuum-assisted biopsy device in the treatment of gynecomastia. Does Health Insurance Cover Breast Reduction Surgery? - GoodRx See Appendix for Table 1. 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. All patients underwent routine investigations to exclude secondary causes of gynecomastia. However, it is unclear if there is any evidence to support this practice. The surgeon must also certify that a certain weight of breast tissue (based on Aetna's table) will be removed in every breast, and not entirely fatty tissue. 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. Philadelphia, PA: W.B. Glatt BS, Sarwer DB, O'Hara DE, et al. 2001;76(5):503-510. 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. 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. Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. Risk factors for complications following breast reduction: Results from a randomized control trial. color: red!important; 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). Plast Reconstr Surg. } 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., breastsize stable over one year) when any of the following criteria (A, B, or C) is met: Member has persistent symptoms in at leasttwoof the anatomical body areas below, directly attributed to macromastia and affecting daily activities for at least1 year: Member has severe breast hypertrophy, documented by high-quality color frontal-view and side-view photographs;and, Women50 years of age or older are required to have a mammogram that was negative for cancer performed within the twoyears prior to the date of the planned reduction mammoplasty;and. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. 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. text-decoration: line-through; Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. The condition not only must be unresponsive to dermatological treatments (e.g., antibiotics or antifungal therapy) and conservative measures (e.g., good skin hygiene, adequate nutrition) for a period of 6 months or longer, but also must satisfy criteria stated insection I above. 18th ed. 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. Patient demographics, surgical technique, and outcomes were analyzed. 2010;125(5):1301-1308. When seeking preauthorization for a breast reduction, your goal is generally twofold. Long-term functional results after reduction mammoplasty. Plastic Reconstruct Surg. Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. Hoyos AE, Perez ME, Dominguez-Millan R, et al. 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). Behmand et al (2000) reported on the results of a questionnaire pre- and post-surgery in 69 subjects from a single practice who underwent reduction mammoplasty. Raispis T, Zehring RD, Downey DL. Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. 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. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. 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. For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. In these cases, breast reduction for men may take 2 to 3 hours. Townsend: Sabiston Textbook of Surgery. Mannu GS, Sudul M, Bettencourt-Silva JH, et al. In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. Satisfactory chest contour was gained in all cases without any abnormality, skin redundancy, or recurrence during the follow-up of 6 to 48 months. The authorsleave the reader with the conclusionthat decisions about the medical necessity of breast reduction surgery in symptomatic women should be left entirely to the surgeon's discretion. Yao Y, Yang Y, Liu J, et al. Seitchik MW. 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. Ages ranged from 18 to 66 years. Does Aetna Cover Breast Reduction? | HelpAdvisor.com Fan L, Yang X, Zhang Y, Jiang J. Endoscopic subcutaneous mastectomy for the treatment of gynecomastia: A report of 65 cases. 2021;74(11):3128-3140. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . Ann Plast Surg. Kalliainen LK; ASPS Health Policy Committee. Asian J Surg. Gynecomastia is a very common concern of male adolescence. Resolution of idiopathic gynecomastia may take several months to years. A total of 15 articles met the inclusion criteria for review. 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? Breast. 2014a;34(1):66-73. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. 2018;7(Suppl 1):S70-S76. The characteristics of patients as well as the curative effects between the 2 groups were analyzed. Will Aetna Insurance Cover my Breast Reduction? - RealSelf.com J Plast Reconstr Aesthet Surg. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. } Gynecomastia may be drug-induced. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. 2012;69(5):510-515. } Women's Health and Cancer Rights Act of 1998. Brown DM, Young VL. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). 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". Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . border: none; 2009;62(2):195-199. The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. American Society of Plastic Surgeons (ASPS). Prepubertal gynecomastia linked to lavender and tea tree oils. .headerBar { PDF Summary of Proposed Aetna Medicare Advantage Agreement list-style-type: decimal; 1999;103(6):1682-1686. color:#eee; What are Aetna breast reduction requirements? - RealSelf.com

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