1995;95(6):1029-1032. Philadelphia, PA: W.B. The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability. Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. 2010;125(5):1301-1308. 2001;76(5):503-510. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). Oncoplastic reduction mammoplasty for breast cancer in women with macromastia: Oncological long-term outcomes. Breast and aesthetic surgery. 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]). Reduction mammoplasty performed solely for cosmetic indications is considered by insurers to be not medically necessary treatment of disease and subject to the standard cosmetic surgery plan exclusion. Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. Devalia HL, Layer GT. In other patients, excess skin and nipple and areola relocation are necessary. J Laparoendosc Adv Surg Tech A. Flancbaum L, Choban PS. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. Nelson et al (2014a) analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. Satisfactory chest contour was gained in all cases without any abnormality, skin redundancy, or recurrence during the follow-up of 6 to 48 months. ER expression did not correlate with the right (p = 0.51) and left 2D: 4D (p = 0.97). 2000;45(6):575-580. Mayo Clin Proc. Gynecomastia is a very common concern of male adolescence. 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. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. Aesthetic Plast Surg. Pediatr Surg Int. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. The average interval between primary and secondary surgery was 14 years (range of 0 to 42 years). Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. Oxfordshire NHS Trust. 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. 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. Computed tomography scan of adrenal glands to identify adrenal lesions. In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. Kasielska-Trojan A, Danilewicz M, Antoszewski B. Burdette TE, Kerrigan CL, Homa KA. Plastic surgery for teenagers briefing paper. OL LI { 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. } } Gland Surg. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. ASPS clinical practice guideline summary on reduction mammaplasty. 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:. Plastic Reconstruct Surg. Initial breast reconstruction including augmentation with implants 15771-15772 (when specific to breast), 19325, 19340, 19342, C1789 Fat grafting (alone, or with implant based feminization) 15771, 15772 *Note: CPT 19318 (breast reduction) includes the work necessary to reposition and reshape the nipple . Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). In this study the National Surgical Quality Improvement Program data set was queried for the Current Procedural Terminology code 19318 from the years 2005 to 2010, with principal outcome measurements of wound complications, surgical site infections, and reoperations. 2009;19(3):e85-e90. background-position: right 65%; The condition not only must be unresponsive to dermatological treatments (e.g., antibiotics or antifungal therapy) and conservative measures (e.g., good skin hygiene, adequate nutrition) for a period of 6 months or longer, but also must satisfy criteria stated insection I above. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. 18th ed. The risks included infection, wound breakdown, scarring, and the need for re-operating. Surgical treatment of gynecomastia: Complications and outcomes. A study by Bruhlmann and Tschopp (1998) was a retrospective study of 246 patients from a surgical practice, approximately 50 % (132) of whom returned a questionnaire about their symptoms and satisfaction with aesthetic results, and their recollection of symptoms prior to surgery. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. Aesthet Plastic Surg. 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. Plast Reconstr Surg. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. Alternatively, you may qualify if your breast size causes significant symptoms, such as: Long-term neck, shoulder or neck pain. width: 100%; 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 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. Surgery. 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 Gynecomastia. list-style-type: decimal; The median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. Plast Reconstr Surg. color: red 2012;130(4):785-789. 2006;118(4):840-848. 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. Patients undergoing surgery for gynecomastia should know that their scars may be visible when they are shirtless. Chadbourne EB, Zhang S, Gordon MJ, et al. 2001;107(5):1234-1240. Although the BRAVO study nominally included a "control group", there was no comparison group of subjects selected from the same cohort, who were randomized or otherwise appropriately assigned to reduce bias, and treated with conservative management according to a protocol to ensure optimal conservative care. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. They also analyzed if timing of reduction mammoplasty in relation to oncological treatment influenced the incidence of abnormal findings, and compared if patients with abnormal contralateral histopathology differed from the study population in terms of demographics. A detailed drug history, including list of medications, an assessment of indirect or environmental exposure to estrogenic compounds, and recreational drug use. Reduction mammoplasty: Criteria for insurance coverage. Breast reduction surgery might also help improve self-image and the ability to take part in physical activities. J Plast Surg Hand Surg. Although operative subjects were examined before and after surgery, there was no attempt to employ any blinded or objective measures of disability and function to verify these self-reports. Cochrane Database Syst Rev. See Appendix for Table 1. Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. 2002;109(5):1556-1566. Plastic Reconstruct Surg. margin-bottom: 38px; The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. 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. Miller AP, Zacher JB, Berggren RB, et al. display: block; Hoyos and colleagues (2021) stated that male chest definition surgery and patients complaining of breast tissue over-growth have been increasing in recent decades. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. J Plast Reconstr Aesthet Surg. ol.numberedList LI { Narula HS, Carlson HE. 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). Breast. The authors concluded that this study was the largest to-date examining the role of tamoxifen in idiopathic gynecomastia, and these findings showed approximately 9 in every 10 men treated with tamoxifen therapy had successful resolution of their symptoms. Mental health care professionals may be consulted to address psychological distress from gynecomastia. For medical 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. In: Townsend CM, Beuchamp RD, Evers BM, eds. 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). OL OL OL LI { 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). Oxford, UK: National Health Service (NHS); October 2008. color:#eee; color: blue!important; Townsend: Sabiston Textbook of Surgery. 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). 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. Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. list-style-type: lower-roman; cursor: pointer; padding: 10px; 2006;9(2):109-114. In a systematic review, these investigators examined the role of radiotherapy in this context. In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. 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 authors concluded that breast re-reduction can be performed safely and predictably, even when the previous technique is not known; and 4 key principles were developed: Language services can be provided by calling the number on your member ID card. Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. Gynaecomastia. Leclere FM, Spies M, Gohritz A, Vogt PM. 2021 Aug 11 [Online ahead of print]. American Society of Plastic Surgeons (ASPS). N Engl J Med. 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: Ann Plast Surg. 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. The majority (87.7 %) of cases presented with accompanying mastalgia. 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). 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. Kerrigan CL, Collins ED, Striplin D, et al. Fischer JP, Cleveland EC, Shang EK, et al. Recommended criteria for insurance coverage of reduction mammoplasty. # font-weight: bold; } Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. font-size: 18px; Type II gynecomastia is more generalized breast enlargement. A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. 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. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. 2019;166(5):934-939. 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. 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. 1998;41(3):240-245. 2013;71(5):471-475. Current concepts in gynaecomastia. } Reduction mammoplasty: Cosmetic or reconstructive procedure? Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. 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. 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. The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. A detailed physical examination, including testicular examination. 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. Gynecomastia in patients with prostate cancer: Update on treatment options. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. Patients with abnormal histopathology could not be pre-operatively identified based on demographics. --> Reduction mammaplasty: A review of managed care medical policy coverage criteria. 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. 2014b;48(5):334-339. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. Plast Reconstr Surg. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. Washington, DC: ACOG; 2011:121-122. Ann Plast Surg. Srinivasaiahet al (2014) stated that although reduction mammoplasty has been shown to benefit physical, physiological, and psycho-social health there are recognized complications. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. of . Please check your insurance policy to see whether breast reduction is a covered procedure. 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. 2008;121(4):1092-1100. It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. 2015;(10):CD007258. Special Clinical Concerns. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. PLoS One. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; Photographs were taken pre-operatively and 1, 3, 6, and 12 months post-operatively. Howrigan P. Reduction and augmentation mammoplasty. Reduction mammaplasty: The need for prospective randomized studies. In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. J Pediatr Surg. Statistical analysis was performed with student t-test and chi-square test. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. The Breast: Comprehensive Management of Benign and Malignant Diseases. } Annu Rev Med. Reduction mammoplasty or breast reduction surgery reduces the volume and weight of the female breasts by removing excess fat, glandular tissue and skin. Surg Laparosc Endosc Percutan Tech. However, it is unclear if there is any evidence to support this practice. (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) Macromastia: all . In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. Li CC, Fu JP, Chang SC, et al. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . Other just require 500 grams no matter what your height and weight. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. OL OL OL OL LI { color: #FFF; 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. 2015;10(8):e0136094. 40 . 2008;32(1):38-44. Marshall WA, Tanner JM. background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; Glatt BS, Sarwer DB, O'Hara DE, et al. With the majority of BBRs performed as an inpatient procedure, there was a trend towards less drain usage in surgeons performing this procedure as an out-patient; however, this was not statistically significant (p = 0.07). The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. Plast Reconstr Surg. margin-top: 38px; padding-right: 18px; The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. When seeking preauthorization for a breast reduction, your goal is generally twofold. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. Brown MH, Weinberg M, Chong N, et al. Reduction mammaplasty: An outcome study. OL OL LI { Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. 2017;35:157-161. 2000;44(2):125-134. 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. The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 %)]. 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. Determinants of surgical site infection after breast surgery. Breast cancer found at the time of breast reduction. Treatment of adolescent gynecomastia. No necrosis, systemic infection, or muscle paralysis was reported. The mean age was 42.8 years (SD 19.5 years). 2nd ed. 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). 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. 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. For many patients the psychological impact of the disease is substantial. Raispis T, Zehring RD, Downey DL. 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. li.bullet { height:2px; Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: A review. Major complications (1.6 %) included unilateral hematoma and localized infection. 2000;106(2):280-288. Risk of bias was assessed independently by 2review authors. Plast Reconstr Surg. Reduction mammaplasty provides long-term improvement in health status and quality of life. These investigators retrospectively examined 83 patients with gynecomastia between January 2015 and December 2019. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). cursor: pointer; Plast Reconstr Surg. Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, . Often times, insurance company will dictate how much breast tissue to be removed. } 1998;26(1):61-65. 1999;103(6):1674-1681. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. Kerrigan CL, Collins ED, Kim HM, et al. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). Beer GM, Kompatscher P, Hergan K. Diagnosis of breast tumors after breast reduction. } Araco A, Gravante G, Araco F, et al. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. .newText { Patient demographics, surgical technique, and outcomes were analyzed. Autorino R, Perdona S, D'Armiento M, et al. The Mammotome procedure represented another novel therapeutic option for gynecomastia. Burns JL, Blackwell SJ. Asian J Surg. breast augmentation with implant. 2007;119(4):1159-1166. } Disproportionately large breasts can cause both physical and emotional . 1969;44(235):291-303. 2009;7(2):114-119. Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. Arlington Heights, IL: ASPRS; 1987.