aetna breast reduction requirements

1999;103(6):1674-1681. Plast Reconstr Surg. ul.ur li{ 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). PDF Summary of Proposed Aetna Medicare Advantage Agreement Plast Reconstr Surg. Plast Reconstr Surg. 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. 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. Breast cancer found at the time of breast reduction. 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. } Gynecomastia. The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. Qu and colleagues (2020) examined the effectiveness of vacuum-assisted breast biopsy systems for the treatment of gynecomastia. Autorino R, Perdona S, D'Armiento M, et al. .newText { Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. Although the BRAVO study is described as a controlled study, the "control" group is obtained, not from the same cohort, but from a separate cohort of individuals recruited from newspaper advertisements and solicitations at meetings for inclusion in a study of the population burden of breast hypertrophy; 75 % of this control group were obtained from2 centers, but the characteristics of those2 centers were not described. Reduction mammoplasty: Criteria for insurance coverage. 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: 2006;30(3):309-319. } Reduction mammoplasty for asymptomatic members is considered cosmetic. Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. 1995;95(6):1029-1032. 2012;69(5):510-515. Oxfordshire NHS Trust. Reduction mammoplasty for macromastia. 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. Breast reduction surgery is considered cosmetic for all indications not listed in section I, A. 1994;21(3):539-543. A non-standardized survey showed a very high satisfaction index. Plastic Reconstr Surg. --> 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. Plast Reconstr Surg. Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: A review. Gynecomastia may be drug-induced. Breast. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. 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? Plast Reconstr Surg. } Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. 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. background-color: #663399; 2011;128(4):243e-249e. Aetna Coverage Denial - 2nd Appeal (They said I'm overweight) Aesthet Surg J. Secondary outcomes included subjective as well as objective assessments of pain and wound healing. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. background-color: #cc0066; 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. These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. margin-bottom: 38px; 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. 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. This will be computed based on your body area. Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? Current concepts in gynaecomastia. padding-bottom: 4px; skin should not be excised horizontally below the inframammary fold. Schnur PL, Hoehn JG, Ilstrup DM, et al. J Laparoendosc Adv Surg Tech A. Collis N, McGuiness CM, Batchelor AG. A total of 244 out of 1,628 patients with the average age of 23.13 years. CG-SURG-71 Reduction Mammaplasty - Anthem PDF Breast Reduction Surgery - Commercial Medical Policy - UHCprovider.com 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. Does Blue Cross Blue Shield Cover Breast Reduction Surgery? - HelpAdvisor 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. Gynecomastia has been classified into2 types. Ann Plast Surg. color: red # color: white; Harmonic scalpel versus electrocautery in breast reduction surgery: A randomized controlled trial. Gynecomastia: Evolving paradigm of management and comparison of techniques. Srinivasaiahet al (2014) stated that although reduction mammoplasty has been shown to benefit physical, physiological, and psycho-social health there are recognized complications. Plast Reconstr Surg. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. 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. Ages ranged from 18 to 66 years. Kalliainen LK; ASPS Health Policy Committee. Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . OL OL OL OL LI { Often times, insurance company will dictate how much breast tissue to be removed. Women's Health and Cancer Rights Act of 1998. and areola. 2021;74(11):3128-3140. In addition, Nguyen et al (2004) ignored a wealth of published evidence of the effectiveness of physical therapy, analgesics and other conservative measures on back and neck pain generally. Surgical treatment of primary gynecomastia in children and adolescents. 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. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. Ann Plast Surg. 2015;75(4):383-387. Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. Arch Dis Child. } However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. 1999;103(6):1682-1686. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. Gland Surg. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. } Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Mizgala CL, MacKenzie KM. Breast Concerns of Adolescents. For the first update of this review, these investigators searched the Cochrane Wounds Group Specialised Register (searched March 4, 2015); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 2); Ovid Medline (2012 to March 3, 2015); Ovid Medline (In-Process & Other Non-Indexed Citations March 3, 2015); Ovid Embase(2012 to March 3, 2015); and EBSCO CINAHL (2012 to March 4, 2015). 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). Little is known about the effect of surgical treatment on the psychological aspects of the disease. Level of Evidence = IV. Narula HS, Carlson HE. 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. Gynecomastia in patients with prostate cancer: Update on treatment options. 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. 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. 2018;24(6):1043-1045. Hoyos and colleagues (2021) stated that male chest definition surgery and patients complaining of breast tissue over-growth have been increasing in recent decades. 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. And if you are in Canada the surgeon decides. Qu S, Zhang W, Li S, et al. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. 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. Subjects were compared to age-matched norms from another study cohort. 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. Level of Evidence = III. color: white; 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). Reduction mammoplasty is among the most commonly performed cosmetic procedures in the United States. Aetna's Itty Bitty Titty Committee - by Libby Watson - Sick Note } Measuring health state preferences in women with breast hypertrophy. } Plast Reconstr Surg. 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. 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. 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). J Plast Surg Hand Surg. 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. How to Get Your Breast Reduction Covered By Insurance - RealSelf News 2021;147(5):1072-1083. Gynecomastia surgery is the surgical correction of over-developed or enlarged breasts in men. .strikeThrough { Bland KI, Copeland EM, eds. list-style-type: lower-roman; Aesthetic Plast Surg. 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. top: 0px; Plast Reconstr Surg. Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. 1997;100(4):875-883. Aetna considers magnetic resonance imaging (MRI), with or without contrast materials, of the breast medically necessary for members who have had a recent (within the past year) conventional mammogram and/or breast sonogram, in any of the following circumstances where MRI of the breast may affect their clinical management:. Asian J Surg. Arlington Heights, IL: ASPS; 2011. PDF A look at new changes coming to E&M and breast coding in 2021 The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. Will Aetna Insurance Cover my Breast Reduction? - RealSelf.com .headerBar { z-index: 99; 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]. See Appendix for Table 1. Coding Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. 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. The characteristics of patients as well as the curative effects between the 2 groups were analyzed. 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). It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. Photographs were taken pre-operatively and 1, 3, 6, and 12 months post-operatively. Plast Reconstr Surg. Based largely upon these results, Nguyen et al (2004) reached the conclusion that a trial of conservative management is not an appropriate criterion for insurance coverage, even though responses to the BRAVO questionnaire indicated that operative candidates and hypertrophy controls received at least some pain relief from all of the conservative interventions, and for some conservative interventions, virtually all subjects reported at least some pain relief. 2007;356(5):479-485. 2015;49(6):311-318. 1997;185(6):593-603. li.bullet { background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. Aesthetic Plast Surg. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the Burdette TE, Kerrigan CL, Homa KA. Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. J Pediatr Surg. In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. 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. Wound drainage after plastic and reconstructive surgery of the breast. Ann Plast Surg. Gynecomastia is a very common concern of male adolescence. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. GP Notebook. Schnur PL, Schnur DP, Petty PM, et al. Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. Most UnitedHealthcare plans have a specific exclusion for breast reduction surgery except as required by the . OL OL OL OL OL LI { 2000;106(5):991-997. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. text-decoration: underline; Behmand RA, Tang DH, Smith DJ Jr. Outcomes in breast reduction surgery. Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). How to make Aetna pay for your breast reduction surgery padding-right: 18px; Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. Breast reduction surgery might also help improve self-image and the ability to take part in physical activities. 2014;20(3):274-278. However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. No necrosis, systemic infection, or muscle paralysis was reported. Reduction mammaplasty: An outcome study. 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. Breast Reconstructive Surgery - Medical Clinical Policy Bulletins - Aetna Ann Plastic Surg. Endocrinol Metab Clin North Am. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. Aesthetic Plast Surg. 2013;71(5):471-475. } 2010;45(3):650-654. 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. } J Plast Reconstr Aesthet Surg. You first need to demonstrate that the procedure is "medically necessary and therefore reconstructive rather than cosmetic," says board-certified New York City plastic surgeon Dr. Umbareen Mahmood. Brown MH, Weinberg M, Chong N, et al. of the following criteria must be met: 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. Plast Reconstr Surg. The Mammotome procedure represented another novel therapeutic option for gynecomastia. The end-point was the complete resolution of gynecomastia. Oncoplastic reduction mammoplasty for breast cancer in women with macromastia: Oncological long-term outcomes. .newText { 1993;91(7):1270-1276. However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance). 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. Determinants of surgical site infection after breast surgery. color: #FFF; Philadelphia, PA: WB Saunders Company; 2008; Ch 73. Tang CL, Brown MH, Levine R, et al. Surgeon. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. Gynecomastia in patients with prostate cancer: A systematic review. Several of the included studies reported improvement in QOL and several psychological domains after surgical treatment for gynecomastia. Level of Evidence = IV. Krieger LM, Lesavoy MA. PLoS One. Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients.

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