font-size: 18px; This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. Socioeconomic Committee Position Paper. Data were prospectively gathered on complications as a part of randomized control trial (RCT) examining psycho-socialand quality of life(QOL) benefits of reduction mammoplasty. Plast Reconstr Surg. Breast J. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. Devalia HL, Layer GT. Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. padding: 15px; Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. 1996;20(5):391-397. 2009;7(2):114-119. The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. 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. 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. 2014b;30(6):641-647. Breast asymmetries: A brief review and our experience. Chadbourne EB, Zhang S, Gordon MJ, et al. Fan L, Yang X, Zhang Y, Jiang J. Endoscopic subcutaneous mastectomy for the treatment of gynecomastia: A report of 65 cases. 2016;20(3):256-260. Br J Plast Surg. 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. 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. 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. 2006;9(2):109-114. Plast Reconstr Surg. } Krieger LM, Lesavoy MA. 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. Plast Reconstr Surg. 2001;108(6):1591-1599. However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. outline: none; The risks included infection, wound breakdown, scarring, and the need for re-operating. Last Review01/04/2023. Prasetyono TOH, Budhipramono AG, Andromeda I, et al. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). 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.. Variations in pattern of pubertal changes in girls. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. 2014a;34(3):409-416. Laituri CA, Garey CL, Ostlie DJ, et al. Reduction mammoplasty for asymptomatic members is considered cosmetic. The nipple-areola complex was re-positioned in 60 % of patients (n = 54). Obstet Gynecol Clin North Am. The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. list-style-type: decimal; Breast hypertrophy. The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. J Laparoendosc Adv Surg Tech A. In a liposuction-only reduction mammoplasty, a small access incision is made in one of the following locations: axillary (under the arm), periareolar (around the nipple) or in the inframammary fold (under the breast). Operative subjects who completed the study reported reductions in pain and improvements in quality of life; however, these improvements may be attributable to placebo effects, the natural history of back pain, other concurrent interventions, regression to the mean, improvements in cosmesis (for quality of life measures), or other confounding variables that may bias in interpretation of results. 1995;61(11):1001-1005. .fixedHeaderWrap { Aesthetic Plast Surg. Breast reduction outcome study. 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. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. 1999;103(6):1674-1681. Li CC, Fu JP, Chang SC, et al. A total of 15 articles met the inclusion criteria for review. 2008;121(4):1092-1100. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aesthetic Plast Surg. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. Burns JL, Blackwell SJ. 2019;166(5):934-939. OL OL OL LI { Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. In: Townsend CM, Beuchamp RD, Evers BM, eds. color: #FFF; } A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. Ann Plastic Surg. of the following criteria must be met: For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). Kasielska-Trojan A, Danilewicz M, Antoszewski B. } Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. Raispis T, Zehring RD, Downey DL. Please check your insurance policy to see whether breast reduction is a covered procedure. This will be computed based on your body area. 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. 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). 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. .headerBar { The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. Surgical treatment of gynecomastia: Complications and outcomes. #backTop:hover { American Society of Plastic and Reconstructive Surgery (ASPRS). Ann Plast Surg. Gynecomastia has been classified into2 types. 1993;91(7):1270-1276. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. 2018;24(6):1043-1045. The majority (87.7 %) of cases presented with accompanying mastalgia. Current concepts in gynaecomastia. Reduction mammaplasty: The need for prospective randomized studies. 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. Mizgala CL, MacKenzie KM. The surgeon estimates that at least the following amounts (in grams) of breast tissue, not fatty tissue, will be removed from each breast, based on the member's body surface area (BSA) calculated using theMosteller formula. Evidence-based clinical practice guideline: Reduction mammaplasty. Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. cursor: pointer; Type II gynecomastia is more generalized breast enlargement. Gynecomastia in patients with prostate cancer: Update on treatment options. 2017;139(6):1313-1322. 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. Tang CL, Brown MH, Levine R, et al. To get insurance coverage, you'll probably need . 2003;111(2):688-694. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. No necrosis, systemic infection, or muscle paralysis was reported. Plast Reconstr Surg. Imahiyerobo TA, Pharmer LA, Swistel AJ, Talmor M. A comparative retrospective analysis of complications after oncoplastic breast reduction and breast reduction for benign macromastia: Are these procedures equally safe? 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. Plast Reconstr Surg. No author listed. Determinants of surgical site infection after breast surgery. 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. PLoS One. Reduction mammaplasty provides long-term improvement in health status and quality of life. Abnormalities in Adolescent Breast Development. 1994;21(3):539-543. 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. When seeking preauthorization for a breast reduction, your goal is generally twofold. padding: 10px; Sood R, Mount DL, Coleman JJ 3rd, et al. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. Arlington Heights, IL: ASPRS; 1987. 2005;58(3):286-289. list-style-type: lower-roman; border: none; Liposuction assisted gynecomastia surgery with minimal periareolar incision: A systematic review. Gland Surg. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. Fischer S, Hirsch T, Hirche C, et al. American Society of Plastic Surgeons (ASPS). 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. Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. (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. Nelson et al (2014a) analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. And if you are in Canada the surgeon decides. Kerrigan CL, Collins ED, Kneeland TS, et al. Ann Plast Surg. 0017 - Breast Reduction Surgery and Gynecomastia Surgery, are met. 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. 1999;103(1):76-82; discussion 83-85. Breast pumps. A total of 244 out of 1,628 patients with the average age of 23.13 years. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. Reduction mammoplasty for macromastia. Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, . 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. 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). 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. The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. Many men with breast enlargement are found to have pseudo-gynecomastia. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). There were 18 out of 415 studies eligible to review. Kerrigan CL, Collins ED, Kim HM, et al. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. Breast. Reduction mammoplasty also known as breast reduction surgery, is a surgical procedure in women to reduce the weight, mass, and size of the breast. The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability. Secondary outcomes included subjective as well as objective assessments of pain and wound healing. Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. 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. 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. Surgical treatment is indicated when medical treatments fail. If an insufficient amount of breast tissue is removed, the surgery is less likely to be successful in relieving pain and any related symptoms from excessive breast weight (e.g., excoriations, rash). 1997;100(4):875-883. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. OL OL LI { J Plast Surg Hand Surg. }. breast augmentation with implant. 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. GP Notebook. Surgeon. 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. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary.
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