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. 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. } 2015;49(6):363-366. Am Surg. Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. Can objective predictors for operative success be identified? The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery group. 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). ol.numberedList LI { Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery. 2018;24(6):1043-1045. 2001;108(6):1591-1599. In: Townsend CM, Beuchamp RD, Evers BM, eds. Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, . Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. Lonie S, Sachs R, Shen A, et al. Aesthetic Plast Surg. These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). No necrosis, systemic infection, or muscle paralysis was reported. 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. 2 . Handschin AE, Bietry D, Hsler R, et al. 2014;20(3):274-278. The median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. 1995;95(6):1029-1032. The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. Well-designed clinical trials provide reliable information about the effectiveness of an intervention, and provide valid information about the characteristics of patients who would benefit from that intervention. Collins ED, Kerrigan CL, Kim M, et al. This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. Imahiyerobo TA, Pharmer LA, Swistel AJ, Talmor M. A comparative retrospective analysis of complications after oncoplastic breast reduction and breast reduction for benign macromastia: Are these procedures equally safe? Plastic Reconstruct Surg. J Plast Surg Hand Surg. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. 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. Last Review01/04/2023. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. 1998;49:215-234. Surgical management of gynecomastia--a 10-year analysis. 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. 2001;76(5):503-510. Plast Reconstr Surg. The surgeon must also certify that a certain weight of breast tissue (based on Aetna's table) will be removed in every breast, and not entirely fatty tissue. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. } Ann Plast Surg. 1995;34(2):113-116. 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. Mental health care professionals may be consulted to address psychological distress from gynecomastia. The Mammotome procedure represented another novel therapeutic option for gynecomastia. Ann Plast Surg. Risk of bias was assessed independently by 2review authors. Aesthet Plastic Surg. Fischer et al (2014a) evaluated predictors of postoperative complications following reduction mammoplasty using the NSQIP) data sets. } The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. The characteristics of patients as well as the curative effects between the 2 groups were analyzed. background-color: #cc0066; It was also found that only 3 % of subjects reported that they had no aesthetic motivation for surgery. 1999;103(6):1674-1681. Furthermore, the lack of an expected "dose-response" relationship between the amount of breast tissue removed and the magnitude of symptomatic relief in these studies raises questions about the validity of these studies and the effectiveness of breast reduction as a method of relieving shoulder and back pain. Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. American Society of Plastic Surgeons (ASPS). From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. 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. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. Prepubertal gynecomastia linked to lavender and tea tree oils. font-size: 18px; 2007;119(4):1159-1166. } 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). Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. 1998;41(3):240-245. 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. 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. .newText { 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 of . 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. Vacuum-assisted minimally invasive mastectomy was performed successfully in all cases, with no residual glands or adipose tissue observed on US. Med Decis Making. Asian J Surg. Only 8 (9.9 %) patients did not have a complete resolution following tamoxifen therapy, of which 2 underwent subsequent surgical resection of their symptomatic gynecomastia. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). Khan SM, Smeulders MJ, Van der Horst CM. Behmand et al (2000) reported on the results of a questionnaire pre- and post-surgery in 69 subjects from a single practice who underwent reduction mammoplasty. hr.separator { Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? 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. 2019;8(4):431-440. Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. Aesthetic Plast Surg. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). 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: Chadbourne EB, Zhang S, Gordon MJ, et al. 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). list-style-type: upper-alpha; Administration of Benefits and Transition Responsibilities 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. 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. 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. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. 1990;24(1):61-67. 2018;89(6):408-412. Breast reduction surgery, also known as reduction mammaplasty, removes fat, breast tissue and skin from the breasts. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. A total of 244 out of 1,628 patients with the average age of 23.13 years. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. A follow-up study of 105 women with breast cancer following reduction mammaplasty. 2014b;30(6):641-647. Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain. The authors stated that operative subjects were told that their responses to the questionnaire were not to be used for insurance and thus the subjects had no motivation to exaggerate symptoms prior to surgery in questionnaire responses; however, it is not clear whether operative subjects would be willing to submit responses to a questionnaire from the doctor that differed substantially from the history that they provided to the doctor during their preoperative evaluation. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. A cohort study of breast cancer risk in breast reduction patients. 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. 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:. Saunders Co.; 1991. J Plast Reconstr Aesthet Surg. See Appendix for Table 1. 2001;108(1):62-67. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. 2009;62(2):195-199. Kerrigan CL, Collins ED, Kneeland TS, et al. Breast reduction surgery (also called reduction mammaplasty) is a type of invasive procedure that involves incisions (cuts) in your skin to decrease the size and weight of your breasts . 2009;19(3):e85-e90. 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. 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. OL OL OL OL LI { 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). 18th ed. For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. 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. Surgical treatment of gynecomastia: Complications and outcomes. Annu Rev Med. The American Society for Plastic Surgery (2011) advises to delay surgery until breast growth ceases: Although waiting may prolong the psychological awkwardness, it is advisable to delay surgery until breast growth ceases in order to achieve the best result. This is similar tothe American College of Obstetricians and Gynaecologists'2011 Guidelines forAdolescent Health Care chapter on breast concerns in adolescents, which states regarding breast hypertrophy: Preferably, treatment should be deferred until breast growth has been completed. 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. Statistical analysis was performed with student t-test and chi-square test. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . width: 100%; list-style-type: upper-roman; However, it is unclear if there is any evidence to support this practice. Level of Evidence = IV. 1999;103(1):76-82; discussion 83-85. 2015;75(4):383-387. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. Qu S, Zhang W, Li S, et al. American Society of Plastic Surgeons (ASPS). Gynecomastia: A systematic review. Gynecomastia: Evolving paradigm of management and comparison of techniques. The requirement for coverage is that the amount of breast tissue to be removed has to be enough to improve your symptoms or function. Ann Plast Surg. Br J Plast Surg. They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. For the first update of this review, these investigators searched the Cochrane Wounds Group Specialised Register (searched March 4, 2015); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 2); Ovid Medline (2012 to March 3, 2015); Ovid Medline (In-Process & Other Non-Indexed Citations March 3, 2015); Ovid Embase(2012 to March 3, 2015); and EBSCO CINAHL (2012 to March 4, 2015). 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. 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. 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). Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. 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%. Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. The end-point was the complete resolution of gynecomastia. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. The Breast: Comprehensive Management of Benign and Malignant Diseases. /*margin-bottom: 43px;*/ Miller AP, Zacher JB, Berggren RB, et al. 2019;166(5):934-939. Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. color: blue Nelson et al (2014a) analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. cursor: pointer; Breast J. This will be computed based on your body area. 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. Kasielska-Trojan A, Danilewicz M, Antoszewski B. A non-standardized survey showed a very high satisfaction index. 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. American Society of Plastic Surgeons (ASPS). 1993;17(3):211-223. Reduction mammoplasty also known as breast reduction surgery, is a surgical procedure in women to reduce the weight, mass, and size of the breast. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. 2008;121(4):1092-1100. J Laparoendosc Adv Surg Tech A. Also, there was no correlation between PR expression and 2D: 4D. Gonzalez FG, Walton RL, Shafer B, et al. Endocrinol Metab Clin North Am. J Pediatr Surg. 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. The following procedures are considered experimental and investigational because there is insufficient evidence of itseffectiveness or itseffectiveness has not been established: Aetna considers breast reduction, surgical mastectomy or liposuction for gynecomastia, either unilateral or bilateral, a cosmetic surgical procedure. A total of 81 patients were included in this study. 2021;74(11):3128-3140. 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. 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. li.bullet { In the case of breast reduction, however, for insurance purposes, it . text-decoration: line-through; The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. The authors concluded that small incisional design for breast parenchymal removal in gynecomastia assisted by liposuction showed a good technical approach for consistent improvement in QOL; however, only 2 studies reported good quality methods of non-randomized case-series urging for a better quality of studies in the future. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. 2006;9(2):109-114. --> Gland Surg. } 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. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. 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. Subjects were compared to age-matched norms from another study cohort. The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. Flancbaum L, Choban PS. display: block; In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. 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. Plast Reconstr Surg. The majority (87.7 %) of cases presented with accompanying mastalgia. This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. 2004;113(1):436-437. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the 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). Scand J Plast Reconstr Hand Surg. Aesthetic Plast Surg. Reduction mammoplasty for asymptomatic members is considered cosmetic. Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. 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. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . OL OL OL OL OL LI { Radiotherapy for prevention or management of gynecomastia recurrence: Future role for general gynecomastia patients in plastic surgery given current role in management of high-risk prostate cancer patients on anti-androgenic therapy. 2006;30(3):309-319. Ann Plastic Surg. 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. Variations in pattern of pubertal changes in girls. Treatment of adolescent gynecomastia. A detailed physical examination, including testicular examination. 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. Abnormalities in Adolescent Breast Development. 2001;107(5):1234-1240. 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. Breast. OL OL LI { 2007;356(5):479-485. 2000;45(6):575-580. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. No data were provided on loss to follow-up. This conclusion is based primarily upon the Breast Reduction Assessment of Value and Outcomes (BRAVO) study, which is described in several articles (Kerrigan et al, 2001; Kerrigan et al, 2002; Collins et al, 2002). Plast Reconstr Surg. Plast Reconstr Surg. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. 1995;95(1):77-83. Long-term functional results after reduction mammoplasty. 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.

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