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: Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. background-color: #cc0066; ul.ur li{ However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. background-position: right 65%; Surgical treatment is indicated when medical treatments fail. 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. Emiroglu M, Salimoglu S, Karaali C, et al. Treating providers are solely responsible for medical advice and treatment of members. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). Priorities Forum Policy Statement. Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: A review. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. These preliminary findings need to be validated by well-designed studies. Reduction mammoplasty or breast reduction surgery reduces the volume and weight of the female breasts by removing excess fat, glandular tissue and skin. Secondary outcomes included subjective as well as objective assessments of pain and wound healing. 2001;108(6):1591-1599. 1991;27(3):232-237. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS). 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. Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. Prepubertal gynecomastia linked to lavender and tea tree oils. Alternatively, you may qualify if your breast size causes significant symptoms, such as: Long-term neck, shoulder or neck pain. 1998;26(1):61-65. Insurers have commonly used the amount of breast tissue to be removed as a criterion for evaluating the medical necessity of breast reduction surgery. text-decoration: underline; The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. Clinical outcomes were measured by operative subjects' responses to a questionnaire about symptoms and quality of life. In a survey of managed care policies regarding breast reduction surgery, Krieger and colleagues reported (2001)found that mostof the respondentsstated that they use weight of excised tissue as the main criterion for allowing the procedure, with anaverage cut-off value of 472 grams for a typicalwoman. 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 total there were 306 women in the 3 trials, and 505 breasts were studied (254 drained, and 251 who were not drained). Another set of breast pump supplies if you get pregnant . Chadbourne EB, Zhang S, Gordon MJ, et al. color:#eee; Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. Please check your insurance policy to see whether breast reduction is a covered procedure. For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. 2017;35:157-161. Aesthet Surg J. color: white; bottom: 20px; The studies used to support the arguments for the medical necessity of breast reduction surgery are poorly controlled and therefore subject to a substantial risk of bias in the interpretation of results. Ann Plastic Surg. Plast Reconstr Surg. Nelson et al (2014b) separately conducted a population level analysis of the 2005-2011 NSQIP datasets, identifying patient who underwent reduction mammoplasty, to determine the impact of obesity on early complications after reduction mammoplasty. Arlington Heights, IL: ASPRS; 1987. background: #5e9732; } Araco A, Gravante G, Araco F, et al. Gynecomastia surgery is the surgical correction of over-developed or enlarged breasts in men. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. Petty PM, Solomon M, Buchel EW, Tran NV. (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. 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. Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? Gynecomastia is a very common concern of male adolescence. 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. Miller AP, Zacher JB, Berggren RB, et al. border: none; Several important points should be considered in evaluating these challenges to insurers' criteria for breast reduction surgery. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. 1999;103(6):1687-1690. The investigators found little difference between obese and non-obese women concerning patient's reports of resolution of symptoms and improvement in body image. Type II gynecomastia is more generalized breast enlargement. OL LI { 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. Breast reduction surgery is considered cosmetic for all indications not listed in section I, A. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. Reduction mammaplasty provides long-term improvement in health status and quality of life. right: 30px; Gynecomastia may be drug-induced. Choban PS, Heckler R, Burge JC, Flancbaum L. Increased incidence of nosocomial infections in obese surgical patients. Many men with breast enlargement are found to have pseudo-gynecomastia. As explained below, the studies used to support the arguments for the medical necessity of breast reduction surgery are poorly controlled and therefore subject to a substantial risk of bias in the interpretation of results. Links to various non-Aetna sites are provided for your convenience only. Devalia HL, Layer GT. Determinants of surgical site infection after breast surgery. 2005;58(3):286-289. Variations in pattern of pubertal changes in girls. 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). Plastic Reconstr Surg. text-decoration: line-through; Breast J. 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). In a within-patient, randomized, patient- and assessor-blinded, controlled study, Anzarut et al (2007) evaluated the use of completely autologous platelet gel in 111 patients undergoing bilateral reduction mammoplasty to reduce post-operative wound drainage. 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. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Oxfordshire NHS Trust. Gland Surg. Ann Plast Surg. However, these medications should be reserved for those with no decrease in breast size after 2 years. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. Fischer S, Hirsch T, Hirche C, et al. 2000;106(2):280-288. Complication rates were inconsistent throughout the studies, ranging from 0.06 % to 26.67 %. In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. 2018;7(Suppl 1):S70-S76. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. Disproportionately large breasts can cause both physical and emotional . 1996;20(5):391-397. Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. 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. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . 2004;113(1):436-437. 2000;45(6):575-580. 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 Copyright Aetna Inc. All rights reserved. ASPS clinical practice guideline summary on reduction mammaplasty. The average interval between primary and secondary surgery was 14 years (range of 0 to 42 years). 1995;34(2):113-116. In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. The mean age was 42.8 years (SD 19.5 years). The following factors were independently associated with any surgical complications: morbid obesity (odds ratio [OR], 2.1; P < .001), active smoking (OR, 1.7; P < .001), history of dyspnea (OR, 2.0; P < .001), and resident participation (OR, 1.8; P = .01) while factors associated with major complications included active smoking (OR, 2.7; P < .001), dyspnea (OR, 2.6; P < .001), resident participation (OR, 2.1; P < .001), and inpatient surgery (OR, 1.8; P = .01). 2014b;48(5):334-339. 2001;107(5):1234-1240. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. 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. 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). Recommended criteria for insurance coverage of reduction mammoplasty. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. For medical Flancbaum L, Choban PS. Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. These investigators searched the literature on the treatment of Simon's grade I and II gynecomastia in PubMed, Scopus, Science Direct, and Cochrane using keywords "gynecomastia" and "liposuction". They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. padding: 10px; 2012;130(4):785-789. 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. Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass 40 . } The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. 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. margin-top: 38px; Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. Sugrue CM, McInerney N, Joyce CW, et al. 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. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. Endocrinol Metab Clin North Am. All patients underwent routine investigations to exclude secondary causes of gynecomastia. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. 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. Risk factors for complications following breast reduction: Results from a randomized control trial. Plast Reconstr Surg. Hoyos AE, Perez ME, Dominguez-Millan R, et al. } Satisfactory chest contour was gained in all cases without any abnormality, skin redundancy, or recurrence during the follow-up of 6 to 48 months. 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]). 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). They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. Among these domains were: vitality, emotional discomfort, limitations due to physical aspects and limitations due to pain. 2002;33:208-217. Burdette TE, Kerrigan CL, Homa KA. The vacuum-assisted breast biopsy system is an effective strategy for the treatment of gynecomastia. Srinivasaiah N, Iwuchukwu OC, Stanley PR, et al. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. Fagerlund A, Lewin R, Rufolo G, et al. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. Ann Chir Plast Esthet. Am Surg. } 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. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. No data were provided on loss to follow-up. 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. 2018;24(6):1043-1045. Ann Plast Surg. 2015;49(6):311-318. of the following criteria must be met: Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. 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. Tang CL, Brown MH, Levine R, et al. 2021;147(5):1072-1083. 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. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. Reduction mammoplasty: Cosmetic or reconstructive procedure? Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. Early complications were rare (6.1%), with superficial skin and soft tissue infections accounting for 45.8% of complications. Breast reduction surgery, also known as reduction mammaplasty, removes fat, breast tissue and skin from the breasts. The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. Aesthetic Plast Surg. A systematic search of the published literature was performed. Plast Reconstr Surg. Surgery. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain.