2005;55(3):227-231. 2004;113(1):436-437. Br J Plast Surg. Ann Plastic Surg. Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. 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. 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. Saunders Co.; 1991. Reduction mammoplasty: Criteria for insurance coverage. Ann Plast Surg. 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. There are alsoseveral earlier, smaller studies that found reductions in symptoms and improvements in quality of life after reduction mammoplasty (Glatt et al, 1999; Bruhlmannand Tschopp, 1998; Blomqvist et al, 2000; and Behmand et al, 2000). height:2px; Gland Surg. } Safran T, Abi-Rafeh J, Alabdulkarim A, et al. Aesthetic Plast Surg. Kerrigan CL, Collins ED, Kneeland TS, et al. 2015;75(4):383-387. Reduction mammaplasty: A review of managed care medical policy coverage criteria. Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass 2006;118(4):840-848. Often times, insurance company will dictate how much breast tissue to be removed. 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. All patients underwent routine investigations to exclude secondary causes of gynecomastia. Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. 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. #backTop:hover { 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. @media print { 2005;58(3):286-289. Aesthetic Plast Surg. Ann Plast Surg. Priorities Forum Policy Statement. Fourth, insurers have provided coverage for reduction mammoplasty in women with excessively large breasts; thus, the debate is about the effectiveness of removal of smaller amounts of breast tissue from women whose breast size most persons would consider within the normal range. Aetna considers breast reconstructive surgery to correct The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 %)]. Annu Rev Med. Aesthet Surg J. cursor: pointer; Although operative subjects were examined before and after surgery, there was no attempt to employ any blinded or objective measures of disability and function to verify these self-reports. } Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). Level of Evidence = IV. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. 2009;19(3):e85-e90. Copyright Aetna Inc. All rights reserved. ER expression did not correlate with the right (p = 0.51) and left 2D: 4D (p = 0.97). Aetna and the City shall each abide by all applicable laws, regulations and government requirements regarding the confidentiality and the safeguarding of individually identifiable health and other personal information, including the privacy and security requirements of HIPAA. Gynecomastia. A total of 15 articles met the inclusion criteria for review. Setala L, Papp A, Joukainen S, et al. 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. 2006;9(2):109-114. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. There were 18 out of 415 studies eligible to review. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. To calculate body surface area (BSA) see:BMI and BSA (Mosteller) Calculator;orBSA (m2) = ([height (in) x weight (lb)]/3131)(denotes square root), BSA (m2) = ([height (cm) x weight (kg)]/3600)(denotes square root). Reduction mammoplasty: Cosmetic or reconstructive procedure? OL OL LI { Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. border-radius: 4px; Surg Laparosc Endosc Percutan Tech. World J Surg. Risk of bias was assessed independently by 2review authors. Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? It's important to note that CPT 19324 - mammaplasty, augmentation without pros-thetic implant - has been deleted. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. Reduction mammoplasty is among the most commonly performed cosmetic procedures in the United States. 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. Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. The authors concluded that small incisional design for breast parenchymal removal in gynecomastia assisted by liposuction showed a good technical approach for consistent improvement in QOL; however, only 2 studies reported good quality methods of non-randomized case-series urging for a better quality of studies in the future. 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. 1996;20(5):391-397. Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). } .fixedHeaderWrap { If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. If reduction mammoplasty was performed before oncological treatment, the incidence of abnormal findings was higher. After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. American Society of Plastic Surgeons (ASPS). .headerBar { Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery group. Ann Plast Surg. 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. 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. Scand J Plast Reconstr Hand Surg. Krieger LM, Lesavoy MA. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. } Healing balms, scented soaps, skin lotions, shampoos and styling gels containing lavender oilor tea tree oil. The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. High-risk lesions (atypical ductal hyperplasia [ADH], atypical lobular hyperplasia [ALH], and lobular carcinoma in situ [LCIS]) were revealed in 37 (11.7 %), and cancer in 6 (1.9 %) patients. 2001;108(1):62-67. Reduction mammoplasty for macromastia. Endocrinol Metab Clin North Am. Macromastia: all . 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. 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. Sugrue CM, McInerney N, Joyce CW, et al. The majority (87.7 %) of cases presented with accompanying mastalgia. Well-designed, prospective, controlled clinical studies have not been performed to assess the effectiveness of surgical removal of modest amounts of breast tissue in reducing neck, shoulder, and back pain and related disability in women. 2018;89(6):408-412. color: red Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. Schnur PL, Hoehn JG, Ilstrup DM, et al. ASPS clinical practice guideline summary on reduction mammaplasty. Gynecomastia in patients with prostate cancer: A systematic review. Tang CL, Brown MH, Levine R, et al. Criteria for reduction mammoplasty surgery from the American Society of Plastic Surgeons (ASPS, 2002; ASPS, 2011) states, among other things, that breast weight or breast volume is not a legitimate criterion upon which to distinguish cosmetic from functional indications. Aesthet Plastic Surg. 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. 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). Karamanos E, Wei B, Siddiqui A, Rubinfeld I. Mistry RM, MacLennan SE, Hall-Findlay EJ. Because reduction mammoplasty may be used for both medically necessary and cosmetic indications, Aetna has set forth above objective criteria to distinguish medically necessary reduction mammoplasty from cosmetic reduction mammoplasty. Burns JL, Blackwell SJ. color: red!important; The mean volume of tissue resected was 250 g (range of 22 to 758 g) from the right breast and 244 g (range of 15 to 705 g) from the left breast. Within this study population, 54.4% of patients were obese (BMI > 30 kg/m2), of which 1308 (28.8%) were Class I (BMI = 30-34.9 kg/m2), 686 (15.1%) were Class II (BMI = 35-39.9 kg/m2), and 439 (9.7%) were Class III (BMI > 40 kg/m2). list-style-type: upper-roman; Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). 2014b;30(6):641-647. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. A study by Glatt et al (1999) was a retrospective analysis of responses to questionnaires sent to patients who underwent reduction mammoplasty regarding physical symptoms and body image. It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. Determinants of surgical site infection after breast surgery. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. Plast Reconstr Surg. Surgical treatment is indicated when medical treatments fail. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. 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. Aesthet Surg J. 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. 1999;103(6):1674-1681. For many patients the psychological impact of the disease is substantial. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS). background-position: right 65%; /*margin-bottom: 43px;*/ Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. 2007;356(5):479-485. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. In other patients, excess skin and nipple and areola relocation are necessary. Burdette TE, Kerrigan CL, Homa KA. 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. Plastic Reconstr Surg. 01/04/2023 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. 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. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. 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. border: none; The Mammotome procedure represented another novel therapeutic option for gynecomastia. Gynecomastia has been classified into2 types. 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). Plast Reconstr Surg. A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. Subjects were compared to age-matched norms from another study cohort. A physician-supervised diet and exercise plan may be indicated in obese patients. Ann Plast Surg. 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. margin-bottom: 38px; 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). /* aetna.com standards styles for templates */ Plast Reconstr Surg. 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. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. 2017;35:157-161. 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. The authors concluded that low-dose radiotherapy to the male breast might be a safe and effective strategy to prevent gynecomastia incidence or recurrence in high-risk patients. Plast Reconstr Surg. 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. The study subjects were stratified into groups based on ages of <60 years and 60 years. } breast augmentation with implant. 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. Policy Statement 6d: Aesthetic surgery procedures. Last Review01/04/2023. Gynecomastia in patients with prostate cancer: Update on treatment options. Plast Reconstr Surg. Ann Plast Surg. Surgical treatment of gynecomastia: Complications and outcomes. Fischer JP, Cleveland EC, Shang EK, et al. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. Measuring health state preferences in women with breast hypertrophy. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. Wound drainage after plastic and reconstructive surgery of the breast. This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . #closethis { Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. A non-standardized survey showed a very high satisfaction index. Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. Reduction mammaplasty: The need for prospective randomized studies. 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. of . The 2 vacuum-assisted breast biopsy systems (Mammotome and Encor) were used for the patients with gynecomastia. Reduction mammoplasty improves symptoms of macromastia. 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. Among these domains were: vitality, emotional discomfort, limitations due to physical aspects and limitations due to pain. Obesity and complications in breast reduction surgery: Are restrictions justified? In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. In these cases, breast reduction for men may take 2 to 3 hours. Several important points should be considered in evaluating these challenges to insurers' criteria for breast reduction surgery. #backTop { Breast reduction surgery, also known as reduction mammaplasty, removes fat, breast tissue and skin from the breasts. Fagerlund A, Cormio L, Palangi L, et al. 2021;147(5):1072-1083. 1998;101(2):361-364. J Plast Reconstr Aesthet Surg. Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. 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). 1993;17(3):211-223. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). Satisfactory chest contour was gained in all cases without any abnormality, skin redundancy, or recurrence during the follow-up of 6 to 48 months. 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. Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. 1999;103(6):1682-1686. 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. 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? 1995;61(11):1001-1005. OL OL OL LI { Abnormalities in Adolescent Breast Development. 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). 2nd ed. 2008;121(4):1092-1100. 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. 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. 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). of the following criteria must be met: 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". OL LI { Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. 2007;36(2):497-519. Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . Reduction mammoplasty or breast reduction surgery reduces the volume and weight of the female breasts by removing excess fat, glandular tissue and skin. The end-point was the complete resolution of gynecomastia. In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. Quality of life after breast reduction. For these reasons, there is insufficient evidence to support the use of reduction mammoplasty, without regard to the size of the breasts or amount of breast tissue to be removed, as a method of relieving chronic back, neck, or shoulder pain. Breast reduction surgery (also called reduction mammaplasty) is a type of invasive procedure that involves incisions (cuts) in your skin to decrease the size and weight of your breasts . 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 . Arlington Heights, IL: ASPS; May 2011. American Society of Plastic and Reconstructive Surgery (ASPRS). Lonie S, Sachs R, Shen A, et al. PLoS One. 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). Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. display: none; Arlington Heights, IL: ASPRS; 1987. There were no restrictions on the basis of date or language of publication. Ages ranged from 18 to 66 years. Analysis was on an intention-to-treat basis. Mizgala CL, MacKenzie KM. Breast pumps. Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne Oxford, UK: National Health Service (NHS); October 2008. 2007;119(4):1159-1166. 2012;69(5):510-515. The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability. Coding An average of 320 specimens were excised from each side with mean blood loss of 34 ml. Reduction mammaplasty. 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. 1995;34(2):113-116. } Plast Reconstr Surg. Plast Reconstr Surg. Surgical management of gynecomastia--a 10-year analysis. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons.