Third, reliable evidence is especially important for pain interventions, because of the waxing and waning nature of pain and the susceptibility of this symptom to placebo effects and other biases that may confound interpretation of study results. Khan SM, Smeulders MJ, Van der Horst CM. 2015;75(4):370-375. A follow-up study of 105 women with breast cancer following reduction mammaplasty. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. Oxford, UK: National Health Service (NHS); October 2008. Handschin AE, Bietry D, Hsler R, et al. 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. Plast Reconstr Surg. Plastic Reconstr Surg. Scand J Plast Reconstr Hand Surg. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). 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. 1997;185(6):593-603. Kerrigan CL, Collins ED, Striplin D, et al. It's important to note that CPT 19324 - mammaplasty, augmentation without pros-thetic implant - has been deleted. 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). In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. Hello! Results illustrated that 3050 patients were <60 years of age (39.7 11.8 years) and 487 were 60 years of age (65.1 4.7 years). For additional language assistance: Chemical exfoliation for acne (eg, acne paste, acid), Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy), Diagnostic mammography, including computer-aided detection (CAD) when performed, Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (eg, lip) by activation of photosensitive drug(s), each phototherapy exposure session, Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug(s) provided by a physician or other qualified health care professional, per day, Basic life and/or disability examination that includes: Measurement of height, weight, and blood pressure; Completion of a medical history following a life insurance pro forma; Collection of blood sample and/or urinalysis complying with "chain of custody" protocols; and Completion of necessary documentation/certificates, Weight management classes, non-physician provider, per session, Mononeuropathies of upper limb [upper extremity paresthesia], Gangrene, not elsewhere classified [tissue necrosis], Non-pressure chronic ulcer of skin of other sites, Hypertrophy of breast [symptomatic-causing significant pain, paresthesias, or ulceration], Other specified disorders of breast [soft tissue infection]. Mistry RM, MacLennan SE, Hall-Findlay EJ. Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. 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. 2014a;34(3):409-416. 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. Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. Townsend: Sabiston Textbook of Surgery. } CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the Management of gynecomastia should include evaluation, including laboratory testing, to identify underlying etiologies. 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. Reduction mammaplasty: Defining medical necessity. Ann Plast Surg. In the case of breast reduction, however, for insurance purposes, it . Analysis was on an intention-to-treat basis. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. Schnur PL, Hoehn JG, Ilstrup DM, et al. To get insurance coverage, you'll probably need . And if you are in Canada the surgeon decides. 2017;35:157-161. J Am Coll Surg. Lonie S, Sachs R, Shen A, et al. cursor: pointer; What are Aetna breast reduction requirements? - RealSelf.com 2008;61(5):493-502. Rising Rates of Insurance Denial for Breast Reduction Surgery Many men with breast enlargement are found to have pseudo-gynecomastia. PDF Procedures, programs and drugs you must precertify - AmeriBen Subjects were compared to age-matched norms from another study cohort. Liposuction assisted gynecomastia surgery with minimal periareolar incision: A systematic review. 2021;147(5):1072-1083. 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. padding-right: 18px; Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: A review. 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. 2015;(10):CD007258. 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. 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. Aesthetic Plast Surg. Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. Variations in pattern of pubertal changes in girls. Breast reduction surgery is considered cosmetic for all indications not listed in section I, A. 2015;49(6):311-318. Risk factors for complications following breast reduction: Results from a randomized control trial. Arlington Heights, IL: ASPS; March 9, 2002. Araco A, Gravante G, Araco F, et al. 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. 1998;49:215-234. The safety, efficacy, complications, and patient satisfactions were recorded during post-operative follow-up periods. 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. Does Blue Cross Blue Shield Cover Breast Reduction Surgery? - HelpAdvisor Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. 2000;106(2):280-288. Reduction mammaplasty: A review of managed care medical policy coverage criteria. Reduction mammoplasty: Cosmetic or reconstructive procedure? Obesity and complications in breast reduction surgery: Are restrictions justified? #backTop:hover { Guidelines for Adolescent Health Care. 2007;119(4):1159-1166. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. 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. Gonzalez FG, Walton RL, Shafer B, et al. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. Li CC, Fu JP, Chang SC, et al. 2008;121(4):1092-1100. Hoyos and colleagues (2021) stated that male chest definition surgery and patients complaining of breast tissue over-growth have been increasing in recent decades. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. 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. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). Copyright Aetna Inc. All rights reserved. } In a systematic review, these investigators examined the role of radiotherapy in this context. Gynecomastia in patients with prostate cancer: A systematic review. 2001;108(1):62-67. 2012;69(5):510-515. Ann Plast Surg. Aesthetic Plast Surg. 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? Please check your insurance policy to see whether breast reduction is a covered procedure. Seitchik MW. 2015;10(8):e0136094. Breast Pump & Breastfeeding Insurance Coverage & Resources | Aetna Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. 0017 - Breast Reduction Surgery and Gynecomastia Surgery, are met. Is breast reduction covered by health insurance? | ASPS Fagerlund A, Cormio L, Palangi L, et al. 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. Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. } Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. Management of gestational gigantomastia. color: blue J Pediatr Surg. Karamanos et al (2015) identified their study as the largest sample on breast reduction in the literature, in which age and surgeon specialty did not correlate with negative results. 1998;101(2):361-364. Aesthet Surg J. 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. Can objective predictors for operative success be identified? Washington, DC: ACOG; 2011:121-122. position: fixed; 2017;139(6):1313-1322. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. Emiroglu M, Salimoglu S, Karaali C, et al. Breast reduction surgery is considered cosmetic and not medically necessary for the following conditions: poor posture, breast asymmetry, pendulousness, problems with clothes fitting properly and nipple-areola distortion. Aetna's Itty Bitty Titty Committee - by Libby Watson - Sick Note Reduction mammaplasty provides long-term improvement in health status and quality of life. } He and associates (2011) examined the safety and feasibility of vacuum-assisted biopsy device in the treatment of gynecomastia. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. } Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. list-style-type: upper-alpha; 1990;24(1):61-67. Reduction mammaplasty: An outcome study. 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. Level of Evidence = IV. margin-top: 38px; Autorino R, Perdona S, D'Armiento M, et al. Plast Reconstr Surg. Fischer et al (2014a) evaluated predictors of postoperative complications following reduction mammoplasty using the NSQIP) data sets. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. Does Health Insurance Cover Breast Reduction Surgery? - GoodRx Level of Evidence = III. Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. Plast Reconstr Surg. list-style-type: lower-roman; Fischer S, Hirsch T, Hirche C, et al. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS). 2013;71(5):471-475. Horm Res Paediatr. background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; Compared with the open surgery group, the vacuum-assisted breast biopsy group had significantly smaller scar sizes left after the operation (5.5 1.3 cm versus 0.8 0.2 cm, p < 0.001), and shorter hospital stay time (5.5 2.4 days versus 3.1 1.6 days, p < 0.001). Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. 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). ol.numberedList LI { list-style-type: upper-roman; The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. 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). Reduction mammaplasty: The need for prospective randomized studies. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. cursor: pointer; padding: 10px; For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. 2000;45(6):575-580. This Clinical Policy Bulletin may be updated and therefore is subject to change. 1999;103(6):1682-1686. The operation was successfully performed in all 20 patients with a mean operating time of 51 mins and a hospital stay of 4 days. 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. No other operation-related complications were observed. Plast Reconstr Surg. However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. 1999;103(6):1687-1690. Kasielska-Trojan A, Danilewicz M, Antoszewski B. A study reporting on a survey of health insurer policies on breast reduction surgery (Nguyen et al, 2004) found that no insurer medical policies could be supported by the medical literature. 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. N Engl J Med. The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. Prostate Cancer Prostatic Dis. Glatt BS, Sarwer DB, O'Hara DE, et al. 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. Level of Evidence = IV. Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. 2018;24(6):1043-1045. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. Furthermore, the lack of an expected "dose-response" relationship between the amount of breast tissue removed and the magnitude of symptomatic relief in these studies raises questions about the validity of these studies and the effectiveness of breast reduction as a method of relieving shoulder and back pain. Obstet Gynecol Clin North Am. Aesthetic Plast Surg. Gynecomastia surgery is the surgical correction of over-developed or enlarged breasts in men. li.bullet { Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance). Plast Reconstr Surg. Flancbaum L, Choban PS. 2005;58(3):286-289. 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). Insurers have commonly used the amount of breast tissue to be removed as a criterion for evaluating the medical necessity of breast reduction surgery. Gynecomastia: A systematic review. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. 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. Devalia HL, Layer GT. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. 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). 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. /*margin-bottom: 43px;*/ The authors concluded that the limited evidence available showed no significant benefit of using post-operative wound drains in reduction mammoplasty, although LOS may be shorter when drains are not used. American Society of Plastic Surgeons (ASPS). Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . Reduction mammoplasty: Criteria for insurance coverage. # font-weight: bold; } Grooving where the bra straps sit on the shoulder. Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. Arlington Heights, IL: ASPRS; 1987. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. 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. Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; } Recommended criteria for insurance coverage of reduction mammoplasty. Evidence-based clinical practice guideline: Reduction mammaplasty. padding-bottom: 4px; 1995;34(2):113-116. Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. 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. } In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. For many patients the psychological impact of the disease is substantial. Ages ranged from 18 to 66 years. If breast growth has been completed, breast reduction surgery is an option. Marshall and Tanner (1969)shows that the final stage of breast maturityoccurs about age 15 on average, but there is wide variation. No author listed. Reduction mammaplasty. All patients underwent routine investigations to exclude secondary causes of gynecomastia. 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. Macromastia: all . Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. Determinants of surgical site infection after breast surgery. 2009;7(2):114-119. The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. Nelson et al (2014b) separately conducted a population level analysis of the 2005-2011 NSQIP datasets, identifying patient who underwent reduction mammoplasty, to determine the impact of obesity on early complications after reduction mammoplasty. Collis N, McGuiness CM, Batchelor AG. font-size: 18px; Kerrigan CL, Collins ED, Kneeland TS, et al. Redundant skin was observed in 1 patient at 1 month post-operatively, whose breast, defined as grade-III, was the largest before operation. 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. 1995;61(11):1001-1005. Aesthetic Plast Surg. Gynecomastia is a very common concern of male adolescence. ASPS clinical practice guideline summary on reduction mammaplasty. Aetna considers breast reconstructive surgery to correct Oxfordshire NHS Trust. 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. 2003;111(2):688-694. Priorities Forum Policy Statement. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. Breast Reduction Surgery: Procedure, Recovery, Cost, and More - Healthline The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. Gynecomastia may be drug-induced. Arlington Heights, IL: ASPS; 2011. 2nd ed. Setala L, Papp A, Joukainen S, et al. 2005;55(3):227-231. A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. list-style-type: decimal; Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. Plastic Reconstruct Surg. Chadbourne EB, Zhang S, Gordon MJ, et al. Little is known about the effect of surgical treatment on the psychological aspects of the disease.