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. Plast Reconstr Surg. Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. The Mammotome procedure represented another novel therapeutic option for gynecomastia. Aesthet Plastic Surg. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. # color: white; This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. 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. Abnormal histopathological findings were more frequent in patients with reduction mammoplasty performed prior to oncological treatment (p < 0.001), and in patients with immediate reconstruction (p = 0.0064). This investigators stated that these studies should include data from older individuals affected by gynecomastia and utilize valid tools of psychological measurement in order to better quantify the effect; elderly patients affected by the disease have been over-looked in the current research; more data on this subject could improve the pre-operative evaluation of these patients and help identify the patients who will benefit from treatment. Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). In fact, according to the American Society of Plastic Surgeons, more than 46,000 breast reduction procedures were performed in 2019, a six percent increase compared to 2018; but in recent years, insurance companies have become more likely to deny coverage for this medically recommended procedure. The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. /*margin-bottom: 43px;*/ The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. 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 author concluded that the current level of evidence on this subject was very low and future studies, examining the impact of the surgical intervention for gynecomastia on psychological domains, are greatly needed. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. 1993;17(3):211-223. Drugs whose mechanism of action is unknown: Others situations which can cause or lead to gynecomastia: The above policy is based on the following references: Last Review Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. Plastic Reconstruct Surg. Narula HS, Carlson HE. Alternatively, you may qualify if your breast size causes significant symptoms, such as: Long-term neck, shoulder or neck pain. 2006;118(4):840-848. Townsend: Sabiston Textbook of Surgery. Ann Plast Surg. Collins ED, Kerrigan CL, Kim M, et al. Gynecomastia in patients with prostate cancer: Update on treatment options. The average age was 24.7 years (range of 18 to 47 years). 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. Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. 2008;32(1):38-44. 2010;45(3):650-654. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. 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. The mean age was 42.8 years (SD 19.5 years). Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. color: red These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. Br J Plast Surg. Follow-up ranged from 2 months to 3 years. 2001;108(6):1591-1599. Araco A, Gravante G, Araco F, et al. 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). Apart from a significantly shorter LOS for those participants who did not have drains (MD 0.77; 95 % CI: 0.40 to 1.14), there was no statistically significant impact of the use of drains on outcomes. Seitchik MW. ASPS clinical practice guideline summary on reduction mammaplasty. The authors concluded that breast re-reduction can be performed safely and predictably, even when the previous technique is not known; and 4 key principles were developed: Language services can be provided by calling the number on your member ID card. Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. Reduction mammoplasty: Criteria for insurance coverage. Qu S, Zhang W, Li S, et al. To get insurance coverage, you'll probably need . A cohort study of breast cancer risk in breast reduction patients. Patients with abnormal histopathology could not be pre-operatively identified based on demographics. Administration of Benefits and Transition Responsibilities 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. 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. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. Ann Plast Surg. 2021 Aug 11 [Online ahead of print]. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. Major complications (1.6 %) included unilateral hematoma and localized infection. 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. 2005;58(3):286-289. Schnur subsequently refuted the validity of the Schnursliding scaleand stated that thescale should no longer be used as a criterion for the determination of insurance coverage for breast reduction surgery (Nguyen et al, 1999). 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). They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. A detailed drug history, including list of medications, an assessment of indirect or environmental exposure to estrogenic compounds, and recreational drug use. 1999;103(6):1687-1690. No necrosis, systemic infection, or muscle paralysis was reported. 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. Annu Rev Med. Breast J. 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 . 1999;103(1):76-82; discussion 83-85. 2008;53(3):255-261. Fagerlund A, Lewin R, Rufolo G, et al. Med Decis Making. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. Sabistons Textbook of Surgery (Burns & Blackwell, 2008)states that breast size should be stable for one year: There is no set lower age limit but, for the adolescent with breast hypertrophy, reduction is deferred until the breasts have stopped growing and are stable in size for at least 12 months before surgery.. Scand J Plast Reconstr Hand Surg. In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. } 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. Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? /* aetna.com standards styles for templates */ 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: padding: 10px; Management of gynecomastia should include evaluation, including laboratory testing, to identify underlying etiologies. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. 2006;30(3):309-319. ul.ur li{ Cochrane Database Syst Rev. Aesthetic Plast Surg. The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. 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. Aesthet Surg J. Mizgala CL, MacKenzie KM. 2 . 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. In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. Gynecomastia is a very common concern of male adolescence. Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain. color:#eee; A non-standardized survey showed a very high satisfaction index. No data were provided on loss to follow-up. of the following criteria must be met: Marshall WA, Tanner JM. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. Early complications were rare (6.1%), with superficial skin and soft tissue infections accounting for 45.8% of complications. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. The health burden of breast hypertrophy. Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. This may lead to additional scarring and additional operating time. Reduction mammaplasty: An outcome study. Arlington Heights, IL: ASPS; March 9, 2002. 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%. J Plast Reconstr Aesthet Surg. 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. .fixedHeaderWrap { This Clinical Policy Bulletin may be updated and therefore is subject to change. Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery group. Setala L, Papp A, Joukainen S, et al. It's important to note that CPT 19324 - mammaplasty, augmentation without pros-thetic implant - has been deleted. Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . And if you are in Canada the surgeon decides. Plast Reconstr Surg. 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). } 2005;55(3):227-231. Moreover, these researchers stated that further studies are needed within the common gynecomastia population managed by plastic surgeons to examine the clinical and economical utility of this intervention before a recommendation for its ubiquitous adoption in plastic surgery can be made to continue improving outcomes for high-risk gynecomastia patients. The primary outcome was the difference in wound drainage over 24 hours. Laituri CA, Garey CL, Ostlie DJ, et al. 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. 2007;119(4):1159-1166. Aetna has their own sliding scale which requires more from smaller patients relative to the Schnur scale, but maxes out at 1000 gms per breast. In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. border-width:0; Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. height:2px; A population-level analysis of bilateral breast reduction: does age affect early complications? No new trials were identified for this first update. 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. Special Clinical Concerns. Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. list-style-type: upper-roman; Bland KI, Copeland EM, eds. Khan SM, Smeulders MJ, Van der Horst CM. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. Krieger LM, Lesavoy MA. breast augmentation with implant. Plastic Reconstruct Surg. 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. Wound drainage after plastic and reconstructive surgery of the breast. 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. Plastic Reconstr Surg. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. Kerrigan CL, Collins ED, Kim HM, et al. 40 . Subjects were compared to age-matched norms from another study cohort. Guidelines for Adolescent Health Care. The vacuum-assisted breast biopsy system is an effective strategy for the treatment of gynecomastia. OL OL LI { All studies on the subject were evaluated for inclusion and 6 studies were included in the review. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. 2021;74(11):3128-3140. 2000;45(6):575-580. Measuring health state preferences in women with breast hypertrophy. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. Plastic Reconstr Surg. A systematic search of the published literature was performed. } From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. 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. Behmand RA, Tang DH, Smith DJ Jr. Outcomes in breast reduction surgery. Reduction mammoplasty for macromastia. } Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. The mean volume of tissue resected was 250 g (range of 22 to 758 g) from the right breast and 244 g (range of 15 to 705 g) from the left breast. 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. Plast Reconstr Surg. Mental health care professionals may be consulted to address psychological distress from gynecomastia. right: 30px; 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. Am Surg. In a systematic review, these investigators examined the role of radiotherapy in this context. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. Reduction mammaplasty: Defining medical necessity. Yao Y, Yang Y, Liu J, et al. 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. Drugs commonly associated with the development of gynecomastia include amphetamines, marijuana, mebrobamate, opiates, amitriptyline, chlordiazepoxide, chlorpromazine, cimetidine, diazepam, digoxin, fluphenazine, haloperidol, imipramine, isoniazid, mesoridazine, methyldopa, perphenazine, phenothiazines, reserpine, spironolactone, thiethylperazine, tricyclic antidepressants, tirfluoperazine, trimeparazine, busulfan, vincristine, tamoxifen, , methyltestosterone, human chorionic gonadotropins, and estrogens. The 2 vacuum-assisted breast biopsy systems (Mammotome and Encor) were used for the patients with gynecomastia. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS). Pediatr Surg Int. Long-term functional results after reduction mammoplasty. 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 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. 2015;(10):CD007258. Risk of bias was assessed independently by 2review authors. 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). 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. 2021;147(5):1072-1083. 1997;185(6):593-603. Coding PLoS One. Evidence-based clinical practice guideline: Reduction mammaplasty. Aesthet Surg J. However, these medications should be reserved for those with no decrease in breast size after 2 years. 18th ed. 2nd ed. No other operation-related complications were observed. Surgical treatment is indicated when medical treatments fail. Level of Evidence = IV. Sugrue CM, McInerney N, Joyce CW, et al. Burns JL, Blackwell SJ. Other just require 500 grams no matter what your height and weight. 01/04/2023 hr.separator { Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. There were no restrictions on the basis of date or language of publication. Gynecomastia in patients with prostate cancer: A systematic review. Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. 2014a;34(1):66-73. Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. 1991;27(3):232-237. World J Surg. 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. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. J Plast Surg Hand Surg. } Arch Dis Child. Current concepts in gynaecomastia. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. Am J Infect Control. Redundant skin was observed in 1 patient at 1 month post-operatively, whose breast, defined as grade-III, was the largest before operation. Ann Plastic Surg. 2014;20(3):274-278. Last Review01/04/2023. Oncoplastic reduction mammoplasty for breast cancer in women with macromastia: Oncological long-term outcomes. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. Breast. Aesthetic Plast Surg. } Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. 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. Schnur PL, Schnur DP, Petty PM, et al. 2014b;48(5):334-339. Tang CL, Brown MH, Levine R, et al. 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. 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). 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). The goals of the surgery are to relieve symptoms caused by heavy breasts, to create a natural, balanced appearance with normal location of the nipple and areola, to maintain the capacity for lactation and allow for future breast exams/mammograms with minimal scarring or decreased sensation. Healing balms, scented soaps, skin lotions, shampoos and styling gels containing lavender oilor tea tree oil. Grooving where the bra straps sit on the shoulder. } 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. The authors recruited 67 consecutive female patients who underwent inferior pedicle reduction mammoplasty in order to determine the effects of resection weight, BMI, age, and smoking on complication rates following reduction mammoplasty. After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. 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. Choban PS, Heckler R, Burge JC, Flancbaum L. Increased incidence of nosocomial infections in obese surgical patients. Plast Reconstr Surg. Reduction mammoplasty or breast reduction surgery reduces the volume and weight of the female breasts by removing excess fat, glandular tissue and skin. It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. Photographs were taken pre-operatively and 1, 3, 6, and 12 months post-operatively. Gynecomastia: Evolving paradigm of management and comparison of techniques. All the patients recovered well and were satisfied with the cosmetic outcomes. Three review authors undertook independent screening of the search results.