Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. 2000;106(5):991-997. The authorsleave the reader with the conclusionthat decisions about the medical necessity of breast reduction surgery in symptomatic women should be left entirely to the surgeon's discretion. outline: none; Treating providers are solely responsible for medical advice and treatment of members. Burns JL, Blackwell SJ. A non-standardized survey showed a very high satisfaction index. 2018;89(6):408-412. After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. text-decoration: line-through; Araco A, Gravante G, Araco F, et al. 01/04/2023 Clinical outcomes were measured by operative subjects' responses to a questionnaire about symptoms and quality of life. 40 . Aesthetic Plast Surg. border-radius: 4px; Plast Reconstr Surg. It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the And if you are in Canada the surgeon decides. } The nipple-areola complex was re-positioned in 60 % of patients (n = 54). Arch Dis Child. Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. hr.separator { Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. 2007;36(2):497-519. 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). OL LI { Oxfordshire NHS Trust. Raispis T, Zehring RD, Downey DL. Breast hypertrophy. } Patients with abnormal histopathology could not be pre-operatively identified based on demographics. 2014;20(3):274-278. Nelson et al (2014a) analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. Plast Reconstr Surg. Surgical treatment of primary gynecomastia in children and adolescents. With approval from the authors institutional ethics committee and written informed consent, a total of 22 patients with 33 abnormally hyperplastic breasts were enrolled at the First Affiliated Hospital with Nanjing Medical University between June 2016 and September 2018. In these cases, breast reduction for men may take 2 to 3 hours. color: red!important; Bertin ML, Crowe J, Gordon SM. 2016;20(3):256-260. A population-level analysis of bilateral breast reduction: does age affect early complications? Level of Evidence = III. Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. Level of Evidence = IV. A detailed physical examination, including testicular examination. Endocrinol Metab Clin North Am. Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. Macromastia: all . Gynecomastia: A systematic review. The characteristics of patients as well as the curative effects between the 2 groups were analyzed. 2009;7(2):114-119. Links to various non-Aetna sites are provided for your convenience only. Radiotherapy was shown to significantly reduce the incidence to a median of 23 %, with all 6 RCTs assessed demonstrating a statistically significant decrease in incidence following radiotherapy prophylaxis. 2002;109(5):1556-1566. Statistical analysis was performed with student t-test and chi-square test. Long-term functional results after reduction mammoplasty. 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. Compared with the open surgery group, the vacuum-assisted breast biopsy group had significantly smaller scar sizes left after the operation (5.5 1.3 cm versus 0.8 0.2 cm, p < 0.001), and shorter hospital stay time (5.5 2.4 days versus 3.1 1.6 days, p < 0.001). 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. Aesthet Surg J. 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). 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. Wound drainage after plastic and reconstructive surgery of the breast. padding: 15px; Socioeconomic Committee Position Paper. The investigators reported that subjects who were of normal weight were as likely to report benefit from reduction mammoplasty as subjects who were over-weight. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Khan SM, Smeulders MJ, Van der Horst CM. Fischer JP, Cleveland EC, Shang EK, et al. border-width:0; 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. 1969;44(235):291-303. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. He Q, Zheng L, Zhuang D, et al. Plastic Reconstruct Surg. 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. Study subjects included 3538 patients with an average age of 43 years and body mass index of 31.6 kg/m(2) and most patients underwent outpatient surgery (80.5%) with an average operative time of 180 minutes.The incidence of overall surgical complications was 5.1% and the incidence of major surgical complications was 2.1%. 1997;100(4):875-883. 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. --> Plastic Reconstr Surg. 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). 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 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: and areola. 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. Mental health care professionals may be consulted to address psychological distress from gynecomastia. Am Surg. } Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. J Am Coll Surg. J Plast Surg Hand Surg. Ann Plastic Surg. ol.numberedList LI { Kasielska-Trojan A, Danilewicz M, Antoszewski B. Petty PM, Solomon M, Buchel EW, Tran NV. Special Clinical Concerns. } 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. Plast Reconstr Surg. 2018;24(6):1043-1045. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). color: blue!important; padding-bottom: 4px; Often times, insurance company will dictate how much breast tissue to be removed. list-style-type : square !important; Surgical treatment of gynecomastia: Complications and outcomes. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. ASPS clinical practice guideline summary on reduction mammaplasty. 2021;147(5):1072-1083. Kerrigan CL, Collins ED, Kim HM, et al. Analysis was on an intention-to-treat basis. Many men with breast enlargement are found to have pseudo-gynecomastia. 1999;103(6):1674-1681. Yao Y, Yang Y, Liu J, et al. 2012;130(4):785-789. 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. 1. } Plast Reconstr Surg. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). list-style-type: lower-alpha; Pediatr Surg Int. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. Evidence-based clinical practice guideline: Reduction mammaplasty. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. Fagerlund A, Lewin R, Rufolo G, et al. Priorities Forum Policy Statement. }. 1998;41(3):240-245. These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. Quality of life after breast reduction. In the case of breast reduction, however, for insurance purposes, it . Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. ASPS Recommended Coverage Criteria for Third Party Payors. Collis N, McGuiness CM, Batchelor AG. 1996;20(5):391-397. Nguyen JT, Wheatley MJ, Schnur PL, et al. 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. Aesthetic Plast Surg. Disproportionately large breasts can cause both physical and emotional . 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. While the efficacy of radiotherapy as a therapeutic modality for gynecomastia was also established, it was shown to be less effective than other available options. 1994;21(3):539-543.

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