OL LI { Plastic Reconstruct Surg. 1995;95(1):77-83. 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. Reduction mammaplasty: Defining medical necessity. border-width:0; American Society of Plastic and Reconstructive Surgery (ASPRS). 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. Gynecomastia. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; It's important to note that CPT 19324 - mammaplasty, augmentation without pros-thetic implant - has been deleted. the nipple-areola complex can be elevated by de-epithelialization rather than recreating or developing a new pedicle; breast tissue is removed where it is in excess, usually inferiorly and laterally; the resection is complemented with liposuction to elevate the bottomed-out inframammary fold; and. 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. J Plast Reconstr Aesthet Surg. 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 reduction surgery is considered cosmetic for all indications not listed in section I, A. Plastic Reconstr Surg. World J Surg. 2006;9(2):109-114. } Reduction mammoplasty for asymptomatic members is considered cosmetic. Prasetyono TOH, Budhipramono AG, Andromeda I, et al. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. 2011;128(4):243e-249e. Reduction mammaplasty: A review of managed care medical policy coverage criteria. Refer to the member's specific plan document for applicable coverage. When seeking preauthorization for a breast reduction, your goal is generally twofold. Aesthetic Plast Surg. The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. Coding 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). Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). The control group was not followed longitudinally or treated according to any protocol to ensure that they received optimal conservative management; conclusions about the lack of effectiveness of conservative management were based on their responses to a questionnaire about whether subjects tried any of 15 conservative interventions, and whether or not they thought these interventions provided relief of symptoms. The majority (87.7 %) of cases presented with accompanying mastalgia. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. Plast Reconstr Surg. 2007;36(2):497-519. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. 1997;185(6):593-603. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. All RCTs that compared the use of a wound drain with no wound drain following plastic and reconstructive surgery of the breast (breast augmentation, breast reduction and breast reconstruction) in women were eligible. The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. 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. list-style-type: decimal; Type II gynecomastia is more generalized breast enlargement. The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability. 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. Surg Laparosc Endosc Percutan Tech. 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. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. 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. Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. Level of Evidence = IV. 2014;20(3):274-278. color: blue!important; Healing balms, scented soaps, skin lotions, shampoos and styling gels containing lavender oilor tea tree oil. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Horm Res Paediatr. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. .fixedHeaderWrap { Gynecomastia may be drug-induced. Macromastia: all . Fischer S, Hirsch T, Hirche C, et al. 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. Plast Reconstr Surg. American Society of Plastic Surgeons (ASPS). In: Townsend CM, Beuchamp RD, Evers BM, eds. If reduction mammoplasty was performed before oncological treatment, the incidence of abnormal findings was higher. Gland Surg. Brown DM, Young VL. It was also found that only 3 % of subjects reported that they had no aesthetic motivation for surgery. In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? Insurers have commonly used the amount of breast tissue to be removed as a criterion for evaluating the medical necessity of breast reduction surgery. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. 2018;7(Suppl 1):S70-S76. Major complications (1.6 %) included unilateral hematoma and localized infection. Aesthetic Plast Surg. Narula HS, Carlson HE. Mannu GS, Sudul M, Bettencourt-Silva JH, et al. 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). Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. Pediatr Surg Int. Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. 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. In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. 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). 2013;71(5):471-475. Several of the included studies reported improvement in QOL and several psychological domains after surgical treatment for gynecomastia. Blomqvist L, Eriksson A, Brandberg Y. Choban PS, Heckler R, Burge JC, Flancbaum L. Increased incidence of nosocomial infections in obese surgical patients. Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. Ann Plastic Surg. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. A total of 15 articles met the inclusion criteria for review. display: none; Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. Qu and colleagues (2020) examined the effectiveness of vacuum-assisted breast biopsy systems for the treatment of gynecomastia. Am Surg. 2 . After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. 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. Hoyos and colleagues (2021) stated that male chest definition surgery and patients complaining of breast tissue over-growth have been increasing in recent decades. 2009;7(2):114-119. 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. 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. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. 2008;121(4):1092-1100. 1999;103(6):1674-1681. Breast cancer found at the time of breast reduction. padding: 15px; The authors reach the remarkable conclusion that a woman with normal sized breasts who has only a few ounces of breast tissue removed is as likely to receive as much benefit from breast reduction surgery as a women with large breasts who has substantially more breast tissue removed. The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. 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. A non-standardized survey showed a very high satisfaction index. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. 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). Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. of . 2009;62(2):195-199. 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. Surgeon. 2001;76(5):503-510. Aesthet Surg J. .strikeThrough { They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. 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. Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. padding-bottom: 4px; A systematic search of the published literature was performed. Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia. 1994;21(3):539-543. 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. Kasielska-Trojan A, Danilewicz M, Antoszewski B. 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. 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. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. } Patient demographics, surgical technique, and outcomes were analyzed. Vacuum-assisted minimally invasive mastectomy was performed successfully in all cases, with no residual glands or adipose tissue observed on US. The mean age was 42.8 years (SD 19.5 years). /*margin-bottom: 43px;*/ Philadelphia, PA: WB Saunders Company; 2008; Ch 73. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. Three review authors undertook independent screening of the search results. A total of 244 out of 1,628 patients with the average age of 23.13 years. Nelson et al (2014a) analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. 2006;30(3):309-319. Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . Copyright Aetna Inc. All rights reserved. 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. A population-level analysis of bilateral breast reduction: does age affect early complications? Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . No data were provided on loss to follow-up. Plastic Reconstr 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. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. Arlington Heights, IL: ASPS; May 2011. Among these domains were: vitality, emotional discomfort, limitations due to physical aspects and limitations due to pain. } Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. Surgery. Determinants of surgical site infection after breast surgery. The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. Gynecomastia: Evolving paradigm of management and comparison of techniques. 2006;118(4):840-848. Drugs commonly associated with the development of gynecomastia include amphetamines, marijuana, mebrobamate, opiates, amitriptyline, chlordiazepoxide, chlorpromazine, cimetidine, diazepam, digoxin, fluphenazine, haloperidol, imipramine, isoniazid, mesoridazine, methyldopa, perphenazine, phenothiazines, reserpine, spironolactone, thiethylperazine, tricyclic antidepressants, tirfluoperazine, trimeparazine, busulfan, vincristine, tamoxifen, , methyltestosterone, human chorionic gonadotropins, and estrogens. Aesthet Plastic Surg. Ages ranged from 18 to 66 years. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). Bland KI, Copeland EM, eds. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. For many patients the psychological impact of the disease is substantial. .newText { All the patients recovered well and were satisfied with the cosmetic outcomes. 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. Glatt BS, Sarwer DB, O'Hara DE, et al. list-style-type: upper-alpha; 2021;147(5):1072-1083. Aetna considers breast reconstructive surgery to correct The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. } } 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. list-style-type: upper-roman; Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. } border: none; Policy Statement 6d: Aesthetic surgery procedures. 2002;109(5):1556-1566. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. } In other patients, excess skin and nipple and areola relocation are necessary. 2000;45(6):575-580. Can objective predictors for operative success be identified? 2015;75(4):383-387. Surgical treatment is indicated when medical treatments fail. 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. background-color:#eee; cursor: pointer; An average of 320 specimens were excised from each side with mean blood loss of 34 ml. A total of 90 patients underwent breast re-reduction surgery. There were no restrictions on the basis of date or language of publication. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . Plast Reconstr Surg. right: 30px; 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. 1999;103(6):1687-1690. Endocrinol Metab Clin North Am. Plast Reconstr Surg. The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. OL OL LI { Kerrigan CL, Collins ED, Striplin D, et al. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. .newText { A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery.
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