For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. Mistry RM, MacLennan SE, Hall-Findlay EJ. 1998;49:215-234. Ann Plast Surg. There were 18 out of 415 studies eligible to review. OL OL OL LI { However, it is unclear if there is any evidence to support this practice. Ann Plast Surg. Plast Reconstr Surg. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). Aesthetic Plast Surg. Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass A total of 90 patients underwent breast re-reduction surgery. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. li.bullet { 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. A non-standardized survey showed a very high satisfaction index. No other operation-related complications were observed. Reduction mammaplasty: A review of managed care medical policy coverage criteria. 1990;24(1):61-67. The authors also noted that patients with BMI greater than 40 kg/m were significantly more likely to develop postoperative wound complications (p = 0.02). 1994;21(3):539-543. 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. 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. Clinical outcomes were measured by operative subjects' responses to a questionnaire about symptoms and quality of life. Management of gestational gigantomastia. of the following criteria must be met: Pediatr Surg Int. Plastic Reconstruct Surg. Risk factors for complications following breast reduction: Results from a randomized control trial. Computed tomography scan of adrenal glands to identify adrenal lesions. Kerrigan CL, Collins ED, Kim HM, et al. Beer GM, Kompatscher P, Hergan K. Diagnosis of breast tumors after breast reduction. Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). background: #5e9732; Leclere FM, Spies M, Gohritz A, Vogt PM. Gynecomastia. Aetna considers breast reconstructive surgery to correct Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. 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. Third, reliable evidence is especially important for pain interventions, because of the waxing and waning nature of pain and the susceptibility of this symptom to placebo effects and other biases that may confound interpretation of study results. Breast J. 1995;95(1):77-83. A total of 15 articles met the inclusion criteria for review. } #closethis { Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. Khan SM, Smeulders MJ, Van der Horst CM. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Vacuum-assisted minimally invasive mastectomy was performed successfully in all cases, with no residual glands or adipose tissue observed on US. } Often times, insurance company will dictate how much breast tissue to be removed. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. Approximately 25 % of the 49 subjects included in this study did not return the post-operative questionnaire. Aetna considers breast reconstructive surgery to correct breast asymmetry cosmetic except for the following conditions: Surgical correction of chest wall deformity causing functional deficit in Poland syndrome when criteria are met in CPB 0272 - Pectus Excavatum and Poland's Syndrome: Surgical Correction; or Setala L, Papp A, Joukainen S, et al. Aesthetic Plast Surg. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). margin-bottom: 38px; Level of Evidence = III. Pseudo-gynecomastia refers to excessive fat tissue or prominent pectoralis muscles. Well-designed, prospective, controlled clinical studies have not been performed to assess the effectiveness of surgical removal of modest amounts of breast tissue in reducing neck, shoulder, and back pain and related disability in women. J Am Coll Surg. 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. PLoS One. Macromastia: all . 2018;24(6):1043-1045. Reduction mammoplasty: Criteria for insurance coverage. Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. For individuals who received radiation treatment to the chest . background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; J Plast Reconstr Aesthet Surg. Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. Narula HS, Carlson HE. Burdette TE, Kerrigan CL, Homa KA. 2017;35:157-161. 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. GP Notebook. Ann Plastic Surg. Nguyen JT, Wheatley MJ, Schnur PL, et al. These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). bottom: 20px; 2020 Sep 4 [Online ahead of print]. OL OL LI { Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . Arlington Heights, IL: ASPRS; 1987. 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. background-color:#eee; Drainage in breast reduction surgery: A prospective randomised intra-patient trail. Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. 2001;107(5):1234-1240. 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. Mental health care professionals may be consulted to address psychological distress from gynecomastia. Tang CL, Brown MH, Levine R, et al. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). Nelson JA, Fischer JP, Chung CU, et al Obesity and early complications following reduction mammaplasty: An analysis of 4545 patients from the 2005-2011 NSQIP datasets. 2019;8(4):431-440. 2015;75(4):383-387. Principles of breast re-reduction: A reappraisal. 1995;95(6):1029-1032. Wound drainage after plastic and reconstructive surgery of the breast. Measuring health state preferences in women with breast hypertrophy. 2010;125(5):1301-1308. 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). A total of 3 RCTs were identified and included in the review out of 190 studies that were initially screened; all evaluated wound drainage after breast reduction surgery. The average interval between primary and secondary surgery was 14 years (range of 0 to 42 years). This Clinical Policy Bulletin may be updated and therefore is subject to change. Major complications (1.6 %) included unilateral hematoma and localized infection. 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: 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 . American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. Another set of breast pump supplies if you get pregnant . 01/04/2023 Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. 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. Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. Plast Reconstr Surg. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. 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]). Copyright Aetna Inc. All rights reserved. Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). 2021;74(11):3128-3140. 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. Reduction mammaplasty provides long-term improvement in health status and quality of life. 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. Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. Gynaecomastia. In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. Recommended criteria for insurance coverage of reduction mammoplasty. Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Scand J Plast Reconstr Hand Surg. In a systematic review, these investigators examined the role of radiotherapy in this context. J Plast Surg Hand Surg. Healing balms, scented soaps, skin lotions, shampoos and styling gels containing lavender oilor tea tree oil. Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. Plast Reconstr Surg. A detailed drug history, including list of medications, an assessment of indirect or environmental exposure to estrogenic compounds, and recreational drug use. Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. 2012;130(4):785-789. Reduction mammoplasty for macromastia. 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. 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. Within this study population, 54.4% of patients were obese (BMI > 30 kg/m2), of which 1308 (28.8%) were Class I (BMI = 30-34.9 kg/m2), 686 (15.1%) were Class II (BMI = 35-39.9 kg/m2), and 439 (9.7%) were Class III (BMI > 40 kg/m2). 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. Special Clinical Concerns. They stated that in the light of these findings, contralateral reduction mammoplasty with histopathological evaluation in breast cancer patients offered a sophisticated tool to catch those patients whose contralateral breast needs increased attention. .strikeThrough { Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammaplasty. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. /* aetna.com standards styles for templates */ Anesthesia may be injected along with saline solution until the tissue is firm, and a suction cannula is used to extract fat from the breast. However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. 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). 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). 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. There were only 2 studies of a total 25 patients that were considered as good in quality. .arrowPurpleSmall, a:hover.arrowPurpleSmall { 1999;103(6):1674-1681. Flancbaum L, Choban PS. For many patients the psychological impact of the disease is substantial. Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. breast augmentation with implant. list-style-type: upper-alpha; ul.ur li{ (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) J Laparoendosc Adv Surg Tech A. Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne N Engl J Med. Many men with breast enlargement are found to have pseudo-gynecomastia. Miller AP, Zacher JB, Berggren RB, et al. } 2 . In total there were 306 women in the 3 trials, and 505 breasts were studied (254 drained, and 251 who were not drained). Insurers have commonly used the amount of breast tissue to be removed as a criterion for evaluating the medical necessity of breast reduction surgery. Surgical management of gynecomastia--a 10-year analysis. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. Treatment of adolescent gynecomastia. This will be computed based on your body area. Kerrigan CL, Collins ED, Striplin D, et al. /*margin-bottom: 43px;*/ z-index: 99; 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. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011.
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