Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. Obstet Gynecol Clin North Am. }. Reduction mammoplasty: Cosmetic or reconstructive procedure? Mannu GS, Sudul M, Bettencourt-Silva JH, et al. Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. color: white; 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. li.bullet { The authors (Nguyen et al, 2004) argue, based primarily on the results of the ASPS-funded BRAVO study (described below), that (with a single exception) no objective criteria for breast reduction surgery are supportable, including criteria based upon the presence of particular signs or symptoms, requirements based upon breast size or the amount of breast tissue removed, any minimum age limitations, any limitation based upon maximum body weight, requirements for a trial of conservative therapy, or the exclusion of certain procedures (liposuction). 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). Management of gynecomastia should include evaluation, including laboratory testing, to identify underlying etiologies. 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. Among these domains were: vitality, emotional discomfort, limitations due to physical aspects and limitations due to pain. Plastic Reconstruct Surg. 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. #backTop:hover { This will be computed based on your body area. 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. American Society of Plastic Surgeons (ASPS). Gynecomastia surgery is the surgical correction of over-developed or enlarged breasts in men. Reduction mammoplasty also known as breast reduction surgery, is a surgical procedure in women to reduce the weight, mass, and size of the breast. 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 . } Devalia HL, Layer GT. 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. No necrosis, systemic infection, or muscle paralysis was reported. 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. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). Plastic Reconstruct Surg. 2017;139(6):1313-1322. The end-point was the complete resolution of gynecomastia. Nguyen JT, Wheatley MJ, Schnur PL, et al. These studies did not find a relationship between breast weight or amount of breast tissue removed and the likelihood of response or magnitude of relief of pain after reduction mammoplasty. 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. 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. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. Aesthet Surg J. 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. Guidelines for Adolescent Health Care. 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. 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. 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). Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. Breast J. 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. He and associates (2011) examined the safety and feasibility of vacuum-assisted biopsy device in the treatment of gynecomastia. } 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. Breast Concerns of Adolescents. The vacuum-assisted breast biopsy system is an effective strategy for the treatment of gynecomastia. } Vacuum-assisted minimally invasive mastectomy was performed successfully in all cases, with no residual glands or adipose tissue observed on US. 2015;(10):CD007258. Breast reduction for symptomatic macromastia. and areola. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. The requirement for coverage is that the amount of breast tissue to be removed has to be enough to improve your symptoms or function. 2017;35:157-161. 2009;7(2):114-119. padding-right: 18px; The author concluded that the current level of evidence on this subject was very low and future studies, examining the impact of the surgical intervention for gynecomastia on psychological domains, are greatly needed. Kalliainen LK; ASPS Health Policy Committee. A non-standardized survey showed a very high satisfaction index. A detailed drug history, including list of medications, an assessment of indirect or environmental exposure to estrogenic compounds, and recreational drug use. Aesthet Plastic Surg. A population-level analysis of bilateral breast reduction: does age affect early complications? For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. } Townsend: Sabiston Textbook of Surgery. 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 example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. Until now, most published research on the subject has focused on how effective surgical treatment is on correcting the cosmetic appearance of the breast. Tang CL, Brown MH, Levine R, et al. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. 1999;103(6):1674-1681. The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. Plast Reconstr Surg. The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. Reduction mammaplasty provides long-term improvement in health status and quality of life. 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 a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. Gland Surg. background-color:#eee; Analysis was on an intention-to-treat basis. 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]). The Mammotome procedure represented another novel therapeutic option for gynecomastia. Patients undergoing surgery for gynecomastia should know that their scars may be visible when they are shirtless. 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: 2020 Sep 4 [Online ahead of print]. 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. Behmand RA, Tang DH, Smith DJ Jr. Outcomes in breast reduction surgery. Plast Reconstr Surg. Breast reduction surgery might also help improve self-image and the ability to take part in physical activities. 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%. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. It's important to note that CPT 19324 - mammaplasty, augmentation without pros-thetic implant - has been deleted. Drugs whose mechanism of action is unknown: Others situations which can cause or lead to gynecomastia: The above policy is based on the following references: Last Review 2015;49(6):311-318. World J Surg. height:2px; Plast Reconstr Surg. 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. Variations in pattern of pubertal changes in girls. 1995;95(6):1029-1032. Measuring health state preferences in women with breast hypertrophy. color: blue Many men with breast enlargement are found to have pseudo-gynecomastia. Aesthetic Plast Surg. Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery group. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. A cohort study of breast cancer risk in breast reduction patients. Determinants of surgical site infection after breast surgery. J Plast Reconstr Aesthet Surg. Gynaecomastia. This investigators stated that these studies should include data from older individuals affected by gynecomastia and utilize valid tools of psychological measurement in order to better quantify the effect; elderly patients affected by the disease have been over-looked in the current research; more data on this subject could improve the pre-operative evaluation of these patients and help identify the patients who will benefit from treatment. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. } Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. 2011;128(4):243e-249e. 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: underline; Plastic Reconstr Surg. Plastic Reconstr Surg. The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. If reduction mammoplasty was performed before oncological treatment, the incidence of abnormal findings was higher. 1998;41(3):240-245. Complication rates were inconsistent throughout the studies, ranging from 0.06 % to 26.67 %. Liposuction assisted gynecomastia surgery with minimal periareolar incision: A systematic review. 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. 2 . 2009;19(3):e85-e90. Note: Breast reduction surgery will be considered medically necessary for women meeting the symptomatic criteria specified above, regardless of BSA, with more than 1 kg of breast tissue to be removed per breast. Washington, DC: ACOG; 2011:121-122. Plast Reconstr Surg. Surgical implications of obesity. 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. 2006;30(3):309-319. Surgical treatment of primary gynecomastia in children and adolescents. For individuals who received radiation treatment to the chest . Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. Plast Reconstr Surg. 1995;95(1):77-83. 1995;61(11):1001-1005. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. 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. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. Exposure to partners using estrogen containing vaginal creams; Cancer chemotherapy (alkylating agents, methotrexate, vinca alkaloids, imatinib, combination chemotherapy), Androgen receptor blockers - bicalutamide, 5 reductase inhibitors - finasteride, dutasteride, Angiotensin converting enzyme inhibitors (captopril, enalapril), Calcium channelblockers(diltiazem, nifedipine, verapamil), Anabolic steroids(e.g., in body builders). } 2021;74(11):3128-3140. list-style-type: lower-alpha; 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. Handschin AE, Bietry D, Hsler R, et al. Statistical analysis was performed with student t-test and chi-square test. text-decoration: line-through; .arrowPurpleSmall, a:hover.arrowPurpleSmall { 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. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. 2000;106(2):280-288. 2014;20(3):274-278. Level of Evidence = III. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. 2009;62(2):195-199. Raispis T, Zehring RD, Downey DL. 2019;8(4):431-440. 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). 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. This may lead to additional scarring and additional operating time. 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. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. The health burden of breast hypertrophy. } Recommended criteria for insurance coverage of reduction mammoplasty. .newText { J Pediatr Surg. No other operation-related complications were observed. It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. 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. 2021 Aug 11 [Online ahead of print]. Kasielska-Trojan A, Danilewicz M, Antoszewski B. 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. 1998;49:215-234. 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. Another set of breast pump supplies if you get pregnant . Endocrinol Metab Clin North Am. 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). In a systematic review, these investigators examined the role of radiotherapy in this context. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. The following procedures are considered experimental and investigational because there is insufficient evidence of itseffectiveness or itseffectiveness has not been established: Aetna considers breast reduction, surgical mastectomy or liposuction for gynecomastia, either unilateral or bilateral, a cosmetic surgical procedure. Cochrane Database Syst Rev. 2014a;34(1):66-73. 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). Petty PM, Solomon M, Buchel EW, Tran NV. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. Little is known about the effect of surgical treatment on the psychological aspects of the disease. American Society of Plastic Surgeons (ASPS). breast augmentation with implant. 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. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. 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. When seeking preauthorization for a breast reduction, your goal is generally twofold. 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. 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. 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. Prasetyono TOH, Budhipramono AG, Andromeda I, et al. Narula HS, Carlson HE. This Clinical Policy Bulletin may be updated and therefore is subject to change. 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. All the patients recovered well and were satisfied with the cosmetic outcomes. background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; Treatment of adolescent gynecomastia. The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. display: none; 2003;111(2):688-694. skin should not be excised horizontally below the inframammary fold. (25 y/o female with a 38J bra size) according to aetna, I should more than qualify for a reduction as I have back, neck, shoulder pain, chest pain and pressure, arm numbness while laying on sides, etc. Disproportionately large breasts can cause both physical and emotional . Aesthetic Plast Surg. 1999;103(1):76-82; discussion 83-85. Links to various non-Aetna sites are provided for your convenience only. Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. Schnur PL, Hoehn JG, Ilstrup DM, et al. Copyright Aetna Inc. All rights reserved. The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. Plast Reconstr Surg. This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. 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). There were only 2 studies of a total 25 patients that were considered as good in quality. 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. Early complications were rare (6.1%), with superficial skin and soft tissue infections accounting for 45.8% of complications. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery. Fagerlund A, Lewin R, Rufolo G, et al. There were no restrictions on the basis of date or language of publication. These investigators retrospectively examined 83 patients with gynecomastia between January 2015 and December 2019. background-position: right 65%; The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne Hello! 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). For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. Plast Reconstr Surg. They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. Several of the included studies reported improvement in QOL and several psychological domains after surgical treatment for gynecomastia. And if you are in Canada the surgeon decides. These preliminary findings need to be validated by well-designed studies. Fischer JP, Cleveland EC, Shang EK, et al.
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