Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. Breast reduction surgery is considered cosmetic for all indications not listed in section I, A. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. z-index: 99; These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). 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 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). The average age of the studied individuals was 25.7 years (SD = 7.8); ER and PR expression was detected in breasts, and digit ratios were calculated in patients with idiopathic gynecomastia. # font-weight: bold; Measuring health state preferences in women with breast hypertrophy. Treating providers are solely responsible for medical advice and treatment of members. 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. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. } Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. 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). This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. Approximately 25 % of the 49 subjects included in this study did not return the post-operative questionnaire. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. color: blue 2007;356(5):479-485. 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. color: #FFF; Annu Rev Med. Cochrane Database Syst Rev. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. background-color: #663399; .arrowPurpleSmall, a:hover.arrowPurpleSmall { ER expression did not correlate with the right (p = 0.51) and left 2D: 4D (p = 0.97). Plast Reconstr Surg. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. 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. Plast Reconstr Surg. Evidence-based clinical practice guideline: Reduction mammaplasty. margin-top: 38px; 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. 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. color:#eee; Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery 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. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. Satisfactory chest contour was gained in all cases without any abnormality, skin redundancy, or recurrence during the follow-up of 6 to 48 months. The average interval between primary and secondary surgery was 14 years (range of 0 to 42 years). 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). If reduction mammoplasty was performed before oncological treatment, the incidence of abnormal findings was higher. J Plast Surg Hand Surg. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. 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. See Appendix for Table 1. top: 0px; .newText { Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. 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. Plastic Reconstr Surg. Level of Evidence = IV. Breast J. cursor: pointer; border-radius: 4px; The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. 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. Khan SM, Smeulders MJ, Van der Horst CM. For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. Current concepts in gynaecomastia. 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). 2002;109(5):1556-1566. The average age was 24.7 years (range of 18 to 47 years). 2009;7(2):114-119. Laituri CA, Garey CL, Ostlie DJ, et al. Many men with breast enlargement are found to have pseudo-gynecomastia. 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). Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. padding-bottom: 4px; Burns JL, Blackwell SJ. 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. If breast growth has been completed, breast reduction surgery is an option. Marshall and Tanner (1969)shows that the final stage of breast maturityoccurs about age 15 on average, but there is wide variation. Fischer et al (2014a) evaluated predictors of postoperative complications following reduction mammoplasty using the NSQIP) data sets. The authors specified the value of these study results was in the identification of morbid obesity as a significant predictor of overall morbidity and active smoking as a strong predictor of major surgical morbidity. 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. Surgeon. #closethis { 2018;24(6):1043-1045. In: Townsend CM, Beuchamp RD, Evers BM, eds. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. li.bullet { 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. 2005;55(3):227-231. 2008;53(3):255-261. Krieger LM, Lesavoy MA. The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. A total of 81 patients were included in this study. } And if you are in Canada the surgeon decides. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. OL LI { 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 . Plast Reconstr Surg. The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. 2000;106(2):280-288. 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. ul.ur li{ Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. Guidelines for Adolescent Health Care. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). 1995;34(2):113-116. Breast cancer found at the time of breast reduction. Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. Surgical treatment of primary gynecomastia in children and adolescents. Determinants of surgical site infection after breast surgery. Three review authors undertook independent screening of the search results. 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. Although the BRAVO study is described as a controlled study, the "control" group is obtained, not from the same cohort, but from a separate cohort of individuals recruited from newspaper advertisements and solicitations at meetings for inclusion in a study of the population burden of breast hypertrophy; 75 % of this control group were obtained from2 centers, but the characteristics of those2 centers were not described. Petty PM, Solomon M, Buchel EW, Tran NV. color: red!important; .strikeThrough { Mayo Clin Proc. Plast Reconstr Surg. Another set of breast pump supplies if you get pregnant . They concluded that higher resection weight, increased BMI, older age, and smoking are risk factors for complication and that patients should therefore be adequately counseled about losing weight and stopping smoking. }. Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. No new trials were identified for this first update. No other operation-related complications were observed. Several important points should be considered in evaluating these challenges to insurers' criteria for breast reduction surgery. The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. The surgeon estimates that at least the following amounts (in grams) of breast tissue, not fatty tissue, will be removed from each breast, based on the member's body surface area (BSA) calculated using theMosteller formula. 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. Until now, most published research on the subject has focused on how effective surgical treatment is on correcting the cosmetic appearance of the breast. In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. Clinical outcomes were measured by operative subjects' responses to a questionnaire about symptoms and quality of life. Surg Laparosc Endosc Percutan Tech. 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. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). margin-bottom: 38px; The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. 2 . Setala L, Papp A, Joukainen S, et al. 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). 01/04/2023 They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? No necrosis, systemic infection, or muscle paralysis was reported. In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. Ann Plastic Surg. Breast reduction surgery, also known as reduction mammaplasty, removes fat, breast tissue and skin from the breasts. A total of 244 out of 1,628 patients with the average age of 23.13 years. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. Kerrigan CL, Collins ED, Kneeland TS, et al. Breast reduction, also known as reduction mammaplasty, is a procedure to remove excess breast fat, glandular tissue and skin to achieve a breast size more in proportion with your body and to alleviate the discomfort associated with excessively large breasts (macromastia). Reduction mammoplasty or breast reduction surgery reduces the volume and weight of the female breasts by removing excess fat, glandular tissue and skin. Schnur PL, Schnur DP, Petty PM, et al. Surgical implications of obesity. 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". Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. 2019;8(4):431-440. Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. Brown MH, Weinberg M, Chong N, et al. Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. Araco A, Gravante G, Araco F, et al. #backTop { Resolution of idiopathic gynecomastia may take several months to years. cursor: pointer; 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. OL OL LI { Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain. Gynecomastia may be drug-induced. For individuals who received radiation treatment to the chest . The Breast: Comprehensive Management of Benign and Malignant Diseases. Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: A review. Aesthet Surg J. Long-term functional results after reduction mammoplasty. Ann Plast Surg. Oncoplastic reduction mammoplasty for breast cancer in women with macromastia: Oncological long-term outcomes. 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). 1. } 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). The Mammotome procedure represented another novel therapeutic option for gynecomastia. 2006;118(4):840-848. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. Collins ED, Kerrigan CL, Kim M, et al. and areola. OL OL OL OL OL LI { Aesthetic Plast Surg. Subjects were compared to age-matched norms from another study cohort. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. Devalia HL, Layer GT. width: 100%; The authors of the BRAVO study reached several conclusions about reduction mammoplasty, most notably that breast size or the amount of breast tissue removed does not have any relationship to the outcome of breast reduction surgery (Kerrigan et al, 2002; Collins et al, 2002). Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. 2001;76(5):503-510. 0017 - Breast Reduction Surgery and Gynecomastia Surgery, are met. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. Townsend: Sabiston Textbook of Surgery. 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. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. Because reduction mammoplasty may be used for both medically necessary and cosmetic indications, Aetna has set forth above objective criteria to distinguish medically necessary reduction mammoplasty from cosmetic reduction mammoplasty. Prasetyono TOH, Budhipramono AG, Andromeda I, et al. Plast Reconstr Surg. For many patients the psychological impact of the disease is substantial. Complication rates were inconsistent throughout the studies, ranging from 0.06 % to 26.67 %. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. 2015;75(4):383-387. They investigated effects of age on 30-day surgical outcomes for reduction mammoplasty with a goal of improving patient care, counseling, and risk stratification on 3537 patients. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). Yao Y, Yang Y, Liu J, et al. Recommended criteria for insurance coverage of reduction mammoplasty. Reduction mammaplasty: A review of managed care medical policy coverage criteria. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. Mental health care professionals may be consulted to address psychological distress from gynecomastia. Plast Reconstr Surg. 2014b;30(6):641-647. Pediatr Surg Int. Reduction mammaplasty: An outcome study. 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. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. Pseudo-gynecomastia refers to excessive fat tissue or prominent pectoralis muscles. Aesthet Plastic Surg. 40 . padding: 15px; 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). The study subjects were stratified into groups based on ages of <60 years and 60 years. Kinell I, Baeusang-Linder M, Ohlsen L. The effect on the preoperative symptoms and the late results of Skoog's reduction mammoplasty: A follow-up study on 149 patients. Raispis T, Zehring RD, Downey DL. 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. 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. It's important to note that CPT 19324 - mammaplasty, augmentation without pros-thetic implant - has been deleted. 2014;20(3):274-278. color: red Reduction mammoplasty for macromastia. A population-level analysis of bilateral breast reduction: does age affect early complications? #backTop:hover { position: fixed; These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. 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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