aetna breast reduction requirements aetna breast reduction requirements

Wound drainage after plastic and reconstructive surgery of the breast. 2014a;34(1):66-73. Resolution of idiopathic gynecomastia may take several months to years. .arrowPurpleSmall, a:hover.arrowPurpleSmall { Fischer et al (2014a) evaluated predictors of postoperative complications following reduction mammoplasty using the NSQIP) data sets. 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. # font-weight: bold; color: red!important; In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. 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. Little is known about the effect of surgical treatment on the psychological aspects of the disease. Plast Reconstr Surg. 1995;95(1):77-83. 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). You may be able to buy a breast pump and supplies from one of our medical equipment suppliers at no charge or at a discounted rate. Refer to the member's specific plan document for applicable coverage. .strikeThrough { position: fixed; 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. Plastic Reconstr Surg. Aetna considers breast reconstructive surgery to correct 1993;91(7):1270-1276. ER expression did not correlate with the right (p = 0.51) and left 2D: 4D (p = 0.97). The authors concluded that breast re-reduction can be performed safely and predictably, even when the previous technique is not known; and 4 key principles were developed: Language services can be provided by calling the number on your member ID card. Breast reduction surgery, also known as reduction mammaplasty, removes fat, breast tissue and skin from the breasts. 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 RA, Tang DH, Smith DJ Jr. Outcomes in breast reduction surgery. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. These preliminary findings need to be validated by well-designed studies. Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. Gynecomastia in patients with prostate cancer: A systematic review. Sugrue and associates (2015) evaluated the current practice patterns of drains usage by plastic and reconstructive and breast surgeons in United kingdom (UK) and Ireland performing bilateral breast reduction (BBR). bottom: 20px; Arlington Heights, IL: ASPS; 2011. 1997;100(4):875-883. Links to various non-Aetna sites are provided for your convenience only. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). Determinants of surgical site infection after breast surgery. Schnur PL, Hoehn JG, Ilstrup DM, et al. height:2px; J Am Coll Surg. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. My Experience of Having Breast Reduction Surgery - Health 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). Aesthetic Plast Surg. Plast Reconstr Surg. list-style-type: upper-roman; @media print { .strikeThrough { Prasetyono TOH, Budhipramono AG, Andromeda I, et al. 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. PDF 0185 Breast Reconstructive Surgery (1) - Aetna For medical margin-top: 38px; 2002;33:208-217. Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. The risks included infection, wound breakdown, scarring, and the need for re-operating. Burns JL, Blackwell SJ. breast augmentation with implant. Fischer S, Hirsch T, Hirche C, et al. 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. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. Breast pumps. Emiroglu M, Salimoglu S, Karaali C, et al. Handschin AE, Bietry D, Hsler R, et al. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. There were only 2 studies of a total 25 patients that were considered as good in quality. 40 . 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. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. A systematic search of the published literature was performed. No author listed. Tang CL, Brown MH, Levine R, et al. 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. 2010;125(5):1301-1308. 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. Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) All patients underwent routine investigations to exclude secondary causes of gynecomastia. 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). Special Clinical Concerns. outline: none; What can I do if my insurance denies coverage for breast reduction? Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. 2001;76(5):503-510. The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 %)]. } 2019;8(4):431-440. 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. For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. 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. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; /*margin-bottom: 43px;*/ Hoyos and colleagues (2021) stated that male chest definition surgery and patients complaining of breast tissue over-growth have been increasing in recent decades. Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia. Aesthet Surg J. Brown MH, Weinberg M, Chong N, et al. Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. He Q, Zheng L, Zhuang D, et al. Plast Reconstr Surg. Level of Evidence = III. Rising Rates of Insurance Denial for Breast Reduction Surgery Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? top: 0px; Quality of life after breast reduction. Setala L, Papp A, Joukainen S, et al. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. 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. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. 2012;69(5):510-515. Plast Reconstr Surg. skin should not be excised horizontally below the inframammary fold. Mistry RM, MacLennan SE, Hall-Findlay EJ. In these cases, breast reduction for men may take 2 to 3 hours. Note: Chronic intertrigo, eczema, dermatitis, and/or ulceration in the infra-mammary fold in and of themselves are not considered medically necessary indications for reduction mammoplasty. Another set of breast pump supplies if you get pregnant . Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance). How to Get Your Breast Reduction Covered By Insurance - RealSelf News What are Aetna breast reduction requirements? - RealSelf.com 1999;103(1):76-82; discussion 83-85. and areola. 2010;45(3):650-654. } Obesity and complications in breast reduction surgery: Are restrictions justified? 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. Breast cancer found at the time of breast reduction. The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. Breast Reduction Surgery | Johns Hopkins Medicine Ann Plast Surg. Breast Reduction Surgery: Procedure, Recovery, Cost, and More - Healthline The surgeon estimates that at least the following amounts (in grams) of breast tissue, not fatty tissue, will be removed from each breast, based on the member's body surface area (BSA) calculated using theMosteller formula. The average amount of tissue removed from an average weight woman (within the 70 to 74.9 kg weight band) in this study was 600 g per breast, with a range of 502 g to 700 g of tissue removed per breast. This was further isolated when comparing morbidly obese patients to non-obese (p < 0.001), class I (p < 0.001), and class II (p = 0.01) patients. Breast reduction surgery - Mayo Clinic Prepubertal gynecomastia linked to lavender and tea tree oils. 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. Risk factors for complications following breast reduction: Results from a randomized control trial. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. GP Notebook. Ann Plast Surg. Breast. 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. 2020 Sep 4 [Online ahead of print]. Seitchik MW. 2021;147(5):1072-1083. 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: The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. Plast Reconstr Surg. American Society of Plastic Surgeons (ASPS). background-color: #663399; Is breast reduction covered by health insurance? | ASPS Well-designed trials are especially important in assessing pain management interventions to isolate the contribution of the intervention from placebo effects, the effects of other concurrently administered pain management interventions, and the natural history of the medical condition. Gynecomastia may be drug-induced. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. Two review authors undertook independent data extraction of study characteristics, methodological quality and outcomes (e.g., infection, other wound complications, pain, and length of hospital stay [LOS]). } Med Decis Making. Leclere FM, Spies M, Gohritz A, Vogt PM. 1991;27(3):232-237. Washington, DC: ACOG; 2011:121-122. J Plast Surg Hand Surg. Plast Reconstr Surg. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. Often times, insurance company will dictate how much breast tissue to be removed. No new trials were identified for this first update. Plastic Reconstruct Surg. Current concepts in gynaecomastia. A physician-supervised diet and exercise plan may be indicated in obese patients. Guidelines for Adolescent Health Care. /* aetna.com standards styles for templates */ Am J Infect Control. } Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . 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. Recommended criteria for insurance coverage of reduction mammoplasty. PLoS One. After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. 2001;107(5):1234-1240. Socioeconomic Committee Position Paper. Sugrue CM, McInerney N, Joyce CW, et al. 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. A study by Bruhlmann and Tschopp (1998) was a retrospective study of 246 patients from a surgical practice, approximately 50 % (132) of whom returned a questionnaire about their symptoms and satisfaction with aesthetic results, and their recollection of symptoms prior to surgery. The goals of the surgery are to relieve symptoms caused by heavy breasts, to create a natural, balanced appearance with normal location of the nipple and areola, to maintain the capacity for lactation and allow for future breast exams/mammograms with minimal scarring or decreased sensation. margin-bottom: 38px; z-index: 99; He and associates (2011) examined the safety and feasibility of vacuum-assisted biopsy device in the treatment of gynecomastia. This trial included all male patients who presented to the authors breast clinic who were diagnosed with primary gynecomastia, and were treated with a trial of tamoxifen 10 mg daily therapy, over a 10-year period from October 2004 to October 2015. Clinical outcomes were measured by operative subjects' responses to a questionnaire about symptoms and quality of life. Gland Surg. 1994;21(3):539-543. 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. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. display: none; 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. 2012;130(4):785-789. Jones SA, Bain JR. Review of data describing outcomes that are used to assess changes in quality of life after reduction mammaplasty. Tang CL, Brown MH, Levine R, et al. 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 . The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. list-style-type: decimal; Araco A, Gravante G, Araco F, et al. Breast reduction surgery might also help improve self-image and the ability to take part in physical activities. In: Townsend CM, Beuchamp RD, Evers BM, eds. Major complications (1.6 %) included unilateral hematoma and localized infection. 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. 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. N Engl J Med. The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. Autorino R, Perdona S, D'Armiento M, et al. 2006;118(4):840-848. Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. 2021;74(11):3128-3140. Annu Rev Med. Surgical treatment is indicated when medical treatments fail. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. 0017 - Breast Reduction Surgery and Gynecomastia Surgery, are met. Mannu GS, Sudul M, Bettencourt-Silva JH, et al. Reduction mammoplasty for macromastia. Long-term functional results after reduction mammoplasty. PDF Breast Reduction Surgery and Gynecomastia Surgery - Aetna #backTop:hover { 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. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. background-color: #cc0066; In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. 2021 Aug 11 [Online ahead of print]. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. Am Surg. 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. Management of gestational gigantomastia. .headerBar { Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. Study subjects included 3538 patients with an average age of 43 years and body mass index of 31.6 kg/m(2) and most patients underwent outpatient surgery (80.5%) with an average operative time of 180 minutes.The incidence of overall surgical complications was 5.1% and the incidence of major surgical complications was 2.1%. 2013;71(5):471-475. Breast reduction for symptomatic macromastia. } 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. Saunders Co.; 1991. color: #FFF; Ages ranged from 18 to 66 years. 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. Fagerlund A, Lewin R, Rufolo G, et al. 2003;111(2):688-694. Surgical treatment of gynecomastia: Complications and outcomes. Please check your insurance policy to see whether breast reduction is a covered procedure. Obstet Gynecol Clin North Am. 1998;101(2):361-364. Plast Reconstr Surg. Gynecomastia: A systematic review. Gonzalez FG, Walton RL, Shafer B, et al. CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. 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. The authors concluded that gynecomastia treatment combining high-definition liposculpture to male breast tissue resection via a new, almost invisible incision allowed these researchers to achieve an athletic and natural appearance of the male pectoral area with a very low rate of complications. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. Reduction mammoplasty performed solely for cosmetic indications is considered by insurers to be not medically necessary treatment of disease and subject to the standard cosmetic surgery plan exclusion. 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). 2005;55(3):227-231. However, these medications should be reserved for those with no decrease in breast size after 2 years. Treating providers are solely responsible for medical advice and treatment of members. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels.