Breast Reduction Surgery and Gynecomastia Surgery - Medical - Aetna Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . Level of Evidence = IV. 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. There were 18 out of 415 studies eligible to review. 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. 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. All the patients recovered well and were satisfied with the cosmetic outcomes. The median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 %)]. list-style-type: upper-alpha; This population-wide analysis - the largest and most heterogeneous study to date - has demonstrated that increasing obesity class is associated with increased early postoperative complications. 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. 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. Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, . Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. 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. 1995;34(2):113-116. 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. Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass This conclusion is based primarily upon the Breast Reduction Assessment of Value and Outcomes (BRAVO) study, which is described in several articles (Kerrigan et al, 2001; Kerrigan et al, 2002; Collins et al, 2002). Cochrane Database Syst Rev. Gynecomastia may be drug-induced. Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. Sugrue CM, McInerney N, Joyce CW, et al. Endocrinol Metab Clin North Am. 2015;75(4):383-387. 2008;53(3):255-261. color:#eee; Arch Dis Child. 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. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. Townsend: Sabiston Textbook of Surgery. 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. border: none; 1998;49:215-234. Many men with breast enlargement are found to have pseudo-gynecomastia. Chadbourne EB, Zhang S, Gordon MJ, et al. Apart from a significantly shorter LOS for those participants who did not have drains (MD 0.77; 95 % CI: 0.40 to 1.14), there was no statistically significant impact of the use of drains on outcomes. Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. 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. 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. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. Computed tomography scan of adrenal glands to identify adrenal lesions. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. Flancbaum L, Choban PS. Reduction mammoplasty: Cosmetic or reconstructive procedure? background: #5e9732; The operation was successfully performed in all 20 patients with a mean operating time of 51 mins and a hospital stay of 4 days. 2006;30(3):309-319. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. Moreover, these researchers stated that further studies are needed within the common gynecomastia population managed by plastic surgeons to examine the clinical and economical utility of this intervention before a recommendation for its ubiquitous adoption in plastic surgery can be made to continue improving outcomes for high-risk gynecomastia patients. Recommended criteria for insurance coverage of reduction mammoplasty. 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. color: blue!important; Sabistons Textbook of Surgery (Burns & Blackwell, 2008)states that breast size should be stable for one year: There is no set lower age limit but, for the adolescent with breast hypertrophy, reduction is deferred until the breasts have stopped growing and are stable in size for at least 12 months before surgery.. Breast Reduction Surgery: Procedure, Recovery, Cost, and More - Healthline The safety, efficacy, complications, and patient satisfactions were recorded during post-operative follow-up periods. Policy. Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. Clinical Policy: Reduction Mammoplasty and Gynecomastia Surgery - WellCare 2008;61(5):493-502. American Society of Plastic Surgeons (ASPS). Links to various non-Aetna sites are provided for your convenience only. 2010;125(5):1301-1308. The investigators reported that subjects who were of normal weight were as likely to report benefit from reduction mammoplasty as subjects who were over-weight. Safran T, Abi-Rafeh J, Alabdulkarim A, et al. 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. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. of . Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. 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. There were no restrictions on the basis of date or language of publication. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Risk of bias was assessed independently by 2review authors. Breast reduction for symptomatic macromastia. N Engl J Med. If reduction mammoplasty was performed before oncological treatment, the incidence of abnormal findings was higher. Well-designed trials are especially important in assessing pain management interventions to isolate the contribution of the intervention from placebo effects, the effects of other concurrently administered pain management interventions, and the natural history of the medical condition. Ann Plast Surg. Plastic surgery for teenagers briefing paper. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. 2002;33:208-217. 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. background-position: right 65%; A follow-up study of 105 women with breast cancer following reduction mammaplasty. There were only 2 studies of a total 25 patients that were considered as good in quality. border-width:0; The average interval between primary and secondary surgery was 14 years (range of 0 to 42 years). Ann Plast Surg. Plast Reconstr Surg. @media print { No new trials were identified for this first update. No data were provided on loss to follow-up. The average age of the studied individuals was 25.7 years (SD = 7.8); ER and PR expression was detected in breasts, and digit ratios were calculated in patients with idiopathic gynecomastia. The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. Aesthet Surg J. OL OL OL OL LI { Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) Schnur PL, Hoehn JG, Ilstrup DM, et al. Harmonic scalpel versus electrocautery in breast reduction surgery: A randomized controlled trial. Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). 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). PDF Procedures, programs and drugs you must precertify - AmeriBen However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. 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. PDF Summary of Proposed Aetna Medicare Advantage Agreement 2000;106(2):280-288. 2015;49(6):311-318. Srinivasaiah N, Iwuchukwu OC, Stanley PR, et al. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. Plastic Reconstruct Surg. } 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. 2015;(10):CD007258. No necrosis, systemic infection, or muscle paralysis was reported. GP Notebook. 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. Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. 2000;106(5):991-997. For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. Plast Reconstr Surg. 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. } 1990;24(1):61-67. 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). Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. Risk factors for complications following breast reduction: Results from a randomized control trial. Reduction mammoplasty for macromastia. 1997;185(6):593-603. Beer GM, Kompatscher P, Hergan K. Diagnosis of breast tumors after breast reduction. Other just require 500 grams no matter what your height and weight. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. In these cases, breast reduction for men may take 2 to 3 hours. Plast Reconstr Surg. Principles of breast re-reduction: A reappraisal. Disproportionately large breasts can cause both physical and emotional . The end-point was the complete resolution of gynecomastia. A cohort study of breast cancer risk in breast reduction patients. Gynecomastia surgery is the surgical correction of over-developed or enlarged breasts in men. It is not intuitively obvious, however, that breast weight would substantially contribute to back, neck and shoulder pain in women with normal or small breasts. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. Ann Plast Surg. 2014b;30(6):641-647. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. 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). 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. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. For medical PDF Breast Reduction Surgery - Commercial Medical Policy - UHCprovider.com 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. } Breast Pump & Breastfeeding Insurance Coverage & Resources | Aetna Is breast reduction covered by health insurance? | ASPS 1997;100(4):875-883. 2019;166(5):934-939. list-style-type: lower-roman; American Society of Plastic Surgeons (ASPS). Aetna considers molecular susceptibility testing for breast and/or epithelial ovarian cancer ("BRCA testing") medically necessary once per lifetime in any of the following categories of high-risk adults with breast or epithelial ovarian cancer (adapted from guidelines from the U.S. Preventive Services Task Force (for The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. 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 for asymptomatic members is considered cosmetic. 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. Plast Reconstr Surg. Patients with abnormal histopathology could not be pre-operatively identified based on demographics. Administration of Benefits and Transition Responsibilities American Society of Plastic and Reconstructive Surgery (ASPRS). This may lead to additional scarring and additional operating time. Rising Rates of Insurance Denial for Breast Reduction Surgery Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. However, it is unclear if there is any evidence to support this practice. 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. 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). 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). 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. Ann Plast Surg. Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. 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). PLoS One. 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. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. color: red position: fixed; 2009;19(3):e85-e90. hr.separator { Kalliainen LK; ASPS Health Policy Committee. --> Breast and aesthetic surgery. In a systematic review, these investigators examined the role of radiotherapy in this context. 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. Photographs were taken pre-operatively and 1, 3, 6, and 12 months post-operatively. Current concepts in gynaecomastia. A population-level analysis of bilateral breast reduction: does age affect early complications? Type II gynecomastia is more generalized breast enlargement. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. Surgical treatment of gynecomastia: Complications and outcomes. 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. 2007;119(4):1159-1166. Fischer JP, Cleveland EC, Shang EK, et al. 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. J Plast Reconstr Aesthet Surg. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes.