1996;20(5):391-397. J Plast Surg Hand Surg. The median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. color: red!important; } text-decoration: underline; 2008;121(4):1092-1100. The Breast: Comprehensive Management of Benign and Malignant Diseases. 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. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. of the following criteria must be met: Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. color: white; 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). Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. The authors concluded that the vacuum-assisted breast biopsy system could be used as a feasible and minimally invasive approach for the treatment of gynecomastia. } Aetna considers breast reconstructive surgery to correct 1997;100(4):875-883. In total there were 306 women in the 3 trials, and 505 breasts were studied (254 drained, and 251 who were not drained). Gynecomastia may be drug-induced. Satisfactory chest contour was gained in all cases without any abnormality, skin redundancy, or recurrence during the follow-up of 6 to 48 months. 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. 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 Scand J Plast Reconstr Hand Surg. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. Breast Reduction Surgery: Procedure, Recovery, Cost, and More - Healthline Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. Kerrigan CL, Collins ED, Kim HM, et al. Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). However, it is unclear if there is any evidence to support this practice. Obstet Gynecol Clin North Am. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. The average age was 24.7 years (range of 18 to 47 years). Alternatively, you may qualify if your breast size causes significant symptoms, such as: Long-term neck, shoulder or neck pain. 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 Gynecomastia in patients with prostate cancer: A systematic review. 2012;69(5):510-515. top: 0px; Collins ED, Kerrigan CL, Kim M, et al. } Plast Reconstr Surg. Please check your insurance policy to see whether breast reduction is a covered procedure. Emiroglu M, Salimoglu S, Karaali C, et al. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. American Society of Plastic and Reconstructive Surgery (ASPRS). /*margin-bottom: 43px;*/ 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. There were no restrictions on the basis of date or language of publication. Surgical removal is rarely indicated and the vast majority of the time is for cosmetic reasons, as there is no functional impairment associated with this disorder. Breast reduction surgery, also known as reduction mammaplasty, removes fat, breast tissue and skin from the breasts. In addition, Nguyen et al (2004) ignored a wealth of published evidence of the effectiveness of physical therapy, analgesics and other conservative measures on back and neck pain generally. Three review authors undertook independent screening of the search results. 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: 2008;61(5):493-502. No data were provided on loss to follow-up. Kasielska-Trojan and associates (2018) analyzed digit ratio in relation to estrogen receptor (ER) and progesterone receptor (PR) expression and verified digit ratio (2D: 4D) as a marker of ER and PR over-expression in the male breast. Does Blue Cross Blue Shield Cover Breast Reduction Surgery? - HelpAdvisor 2007;356(5):479-485. #backTop { A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. Plast Reconstr Surg. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. border: none; Plast Reconstr Surg. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. OL LI { Devalia HL, Layer GT. Plast Reconstr Surg. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. --> 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. 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. How to make Aetna pay for your breast reduction surgery A detailed physical examination, including testicular examination. z-index: 99; Aesthetic Plast Surg. Reduction mammaplasty: Defining medical necessity. 2008;32(1):38-44. Aesthet Surg J. 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. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. 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. 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. Guidelines for Adolescent Health Care. 1995;61(11):1001-1005. 2009;19(3):e85-e90. J Am Coll Surg. Aesthetic Plast Surg. Reduction mammoplasty: Criteria for insurance coverage. Arlington Heights, IL: ASPS; March 9, 2002. Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. Obesity and complications in breast reduction surgery: Are restrictions justified? Reduction mammoplasty for macromastia. padding-bottom: 4px; Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. Long-term functional results after reduction mammoplasty. These investigators retrospectively examined 83 patients with gynecomastia between January 2015 and December 2019. If reduction mammoplasty was performed before oncological treatment, the incidence of abnormal findings was higher. Computed tomography scan of adrenal glands to identify adrenal lesions. 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. 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. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. Prepubertal gynecomastia linked to lavender and tea tree oils. The requirement for coverage is that the amount of breast tissue to be removed has to be enough to improve your symptoms or function. For additional language assistance: Chemical exfoliation for acne (eg, acne paste, acid), Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy), Diagnostic mammography, including computer-aided detection (CAD) when performed, Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (eg, lip) by activation of photosensitive drug(s), each phototherapy exposure session, Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug(s) provided by a physician or other qualified health care professional, per day, Basic life and/or disability examination that includes: Measurement of height, weight, and blood pressure; Completion of a medical history following a life insurance pro forma; Collection of blood sample and/or urinalysis complying with "chain of custody" protocols; and Completion of necessary documentation/certificates, Weight management classes, non-physician provider, per session, Mononeuropathies of upper limb [upper extremity paresthesia], Gangrene, not elsewhere classified [tissue necrosis], Non-pressure chronic ulcer of skin of other sites, Hypertrophy of breast [symptomatic-causing significant pain, paresthesias, or ulceration], Other specified disorders of breast [soft tissue infection]. An 18-question survey was created evaluating various aspects of BBR practice; UK and Irish plastic and reconstructive and breast surgeons were invited to participate by an e-mail containing a link to a web-based survey. Quality of life after breast reduction. 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. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. Priorities Forum Policy Statement. Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia. However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. Gynecomastia has been classified into2 types. The mean age was 42.8 years (SD 19.5 years). } Breast Reduction Surgery | Johns Hopkins Medicine Breast. Follow-up ranged from 2 months to 3 years. 2021;74(11):3128-3140. Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. Aetna and the City shall each abide by all applicable laws, regulations and government requirements regarding the confidentiality and the safeguarding of individually identifiable health and other personal information, including the privacy and security requirements of HIPAA. PDF Clinical Policy Bulletin: Cosmetic Surgery - Aetna Mannu GS, Sudul M, Bettencourt-Silva JH, et al. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. Disproportionately large breasts can cause both physical and emotional . The health burden of breast hypertrophy. Gonzalez FG, Walton RL, Shafer B, et al. list-style-type: upper-roman; 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 . li.bullet { Measuring health state preferences in women with breast hypertrophy. Breast cancer found at the time of breast reduction. } Flancbaum L, Choban PS. Breast Reduction Surgery and Gynecomastia Surgery - Medical - Aetna Howrigan P. Reduction and augmentation mammoplasty. Gynaecomastia. 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). 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. color:#eee; Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. Safran T, Abi-Rafeh J, Alabdulkarim A, et al. Yao Y, Yang Y, Liu J, et al. Araco A, Gravante G, Araco F, et al. 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. Major complications (1.6 %) included unilateral hematoma and localized infection. outline: none; Med Decis Making. Mizgala CL, MacKenzie KM. The primary outcome was the difference in wound drainage over 24 hours. Subjects were compared to age-matched norms from another study cohort. } 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. Clinical outcomes were measured by operative subjects' responses to a questionnaire about symptoms and quality of life. PDF Gender Dysphoria Treatment - Cigna Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). Aesthetic Plast Surg. 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. Arlington Heights, IL: ASPRS; 1987. .fixedHeaderWrap { Surgeon. Determinants of surgical site infection after breast surgery. Asian J Surg. 2011;128(4):243e-249e. Second, it is the burden of the proponent of an intervention to provide reliable evidence of its effectiveness, not the burden of ones whoquestion the effectivenessan intervention to provide definitive proof of ineffectiveness. 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). Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. Cochrane Database Syst Rev. 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. 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. Breast pumps. For individuals who received radiation treatment to the chest . All studies on the subject were evaluated for inclusion and 6 studies were included in the review. Type II gynecomastia is more generalized breast enlargement. position: fixed; # font-weight: bold; Plast Reconstr Surg. Variations in pattern of pubertal changes in girls. 1969;44(235):291-303. color: blue Policy. Evidence-based clinical practice guideline: Reduction mammaplasty. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. 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. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). Ann Plastic Surg. Leclere FM, Spies M, Gohritz A, Vogt PM. The operation was successfully performed in all 20 patients with a mean operating time of 51 mins and a hospital stay of 4 days. 2007;119(4):1159-1166. A population-level analysis of bilateral breast reduction: does age affect early complications? Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). 1999;103(6):1687-1690. } The safety, efficacy, complications, and patient satisfactions were recorded during post-operative follow-up periods. J Plast Surg Hand Surg. } border-radius: 4px; list-style-type: lower-alpha; A total of 15 articles met the inclusion criteria for review. 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. 2nd ed. 1995;95(6):1029-1032. 2014b;48(5):334-339. hr.separator { Plast Reconstr Surg. display: none; Collis N, McGuiness CM, Batchelor AG. 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. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. No other operation-related complications were observed. Also, there was no correlation between PR expression and 2D: 4D. # color: white; If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. 1998;101(2):361-364. The investigators found that comorbid conditions increased across obesity classifications (p < 0.001), with significant differences noted in all cohort comparisons except when comparing class I to class II (p = 0.12). 2014a;34(1):66-73. For many patients the psychological impact of the disease is substantial. 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. Will Aetna Insurance Cover my Breast Reduction? - RealSelf.com Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. Photographs were taken pre-operatively and 1, 3, 6, and 12 months post-operatively. Plastic Reconstr Surg. 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. Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. What can I do if my insurance denies coverage for breast reduction? 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). A total of 81 patients were included in this study. 1999;103(6):1682-1686. Plast Reconstr Surg. 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, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. This may lead to additional scarring and additional operating time. Patient demographics, surgical technique, and outcomes were analyzed. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. Level of Evidence = IV. Karamanos et al (2015) identified their study as the largest sample on breast reduction in the literature, in which age and surgeon specialty did not correlate with negative results. Gynecomastia surgery is the surgical correction of over-developed or enlarged breasts in men. The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications.