If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. To calculate body surface area (BSA) see:BMI and BSA (Mosteller) Calculator;orBSA (m2) = ([height (in) x weight (lb)]/3131)(denotes square root), BSA (m2) = ([height (cm) x weight (kg)]/3600)(denotes square root). Long-term functional results after reduction mammoplasty. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. American Society of Plastic and Reconstructive Surgery (ASPRS). The characteristics of patients as well as the curative effects between the 2 groups were analyzed. Washington, DC: ACOG; 2011:121-122. Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. Recommended criteria for insurance coverage of reduction mammoplasty. Note: Chronic intertrigo, eczema, dermatitis, and/or ulceration in the infra-mammary fold in and of themselves are not considered medically necessary indications for reduction mammoplasty. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. Jones SA, Bain JR. Review of data describing outcomes that are used to assess changes in quality of life after reduction mammaplasty. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. skin should not be excised horizontally below the inframammary fold. } Philadelphia, PA: WB Saunders Company; 2008; Ch 73. 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 . Computed tomography scan of adrenal glands to identify adrenal lesions. Evidence-based clinical practice guideline: Reduction mammaplasty. The Mammotome procedure represented another novel therapeutic option for gynecomastia. Yao Y, Yang Y, Liu J, et al. } Fan L, Yang X, Zhang Y, Jiang J. Endoscopic subcutaneous mastectomy for the treatment of gynecomastia: A report of 65 cases. N Engl J Med. The investigators found little difference between obese and non-obese women concerning patient's reports of resolution of symptoms and improvement in body image. 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. # font-weight: bold; Schnur PL, Hoehn JG, Ilstrup DM, et al. Plast Reconstr Surg. display: none; 1997;100(4):875-883. 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. Reduction mammoplasty: Criteria for insurance coverage. When seeking preauthorization for a breast reduction, your goal is generally twofold. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). 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). Healing balms, scented soaps, skin lotions, shampoos and styling gels containing lavender oilor tea tree oil. 2006;118(4):840-848. Plast Reconstr Surg. Analysis was on an intention-to-treat basis. These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). Determinants of surgical site infection after breast surgery. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. 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%. Inclusion criteria were as follows: men diagnosed with gynecomastia and BMI of less than or equal to 32 kg/m2, adequate skin elasticity, and general good health. Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). Can objective predictors for operative success be identified? J Laparoendosc Adv Surg Tech A. 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). It was also found that only 3 % of subjects reported that they had no aesthetic motivation for surgery. Plast Reconstr Surg. This will be computed based on your body area. 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. hr.separator { color:#eee; Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain. height:2px; How to make Aetna pay for your breast reduction surgery Please check your insurance policy to see whether breast reduction is a covered procedure. A total of 244 out of 1,628 patients with the average age of 23.13 years. 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. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. Aesthetic Plast Surg. padding-bottom: 4px; A detailed physical examination, including testicular examination. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. J Pediatr Surg. bottom: 20px; Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. } 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. color: blue 2021;147(5):1072-1083. Gynecomastia in patients with prostate cancer: A systematic review. Brown MH, Weinberg M, Chong N, et al. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. Breast reduction surgery - Mayo Clinic 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. In a within-patient, randomized, patient- and assessor-blinded, controlled study, Anzarut et al (2007) evaluated the use of completely autologous platelet gel in 111 patients undergoing bilateral reduction mammoplasty to reduce post-operative wound drainage. Devalia HL, Layer GT. 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. 2008;61(5):493-502. Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). This may lead to additional scarring and additional operating time. cursor: pointer; 2013;71(5):471-475. They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. Petty PM, Solomon M, Buchel EW, Tran NV. Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. 2019;166(5):934-939. 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. The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. Mizgala CL, MacKenzie KM. This was further isolated when comparing morbidly obese patients to non-obese (p < 0.001), class I (p < 0.001), and class II (p = 0.01) patients. 2007;119(4):1159-1166. American Society of Plastic Surgeons (ASPS). Reduction mammaplasty: An outcome study. Surgical implications of obesity. 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. 2000;44(2):125-134. Kerrigan CL, Collins ED, Kneeland TS, et al. 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). 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. Reduction mammaplasty. Gland Surg. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. 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. The health burden of breast hypertrophy. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. list-style-type: lower-alpha; color: red Ages ranged from 18 to 66 years. 2012;69(5):510-515. In other patients, excess skin and nipple and areola relocation are necessary. Surgical treatment of primary gynecomastia in children and adolescents. Beer GM, Kompatscher P, Hergan K. Diagnosis of breast tumors after breast reduction. A non-standardized survey showed a very high satisfaction index. Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. Disproportionately large breasts can cause both physical and emotional . Secondary outcomes included subjective as well as objective assessments of pain and wound healing. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Kasielska-Trojan A, Danilewicz M, Antoszewski B. border-radius: 4px; 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. Prepubertal gynecomastia linked to lavender and tea tree oils. PDF Gender Dysphoria Treatment - Cigna Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. A follow-up study of 105 women with breast cancer following reduction mammaplasty. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. The majority (87.7 %) of cases presented with accompanying mastalgia. 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. 2014b;48(5):334-339. } Gynecomastia. 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. 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). list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; Fischer S, Hirsch T, Hirche C, et al. Gynaecomastia. J Plast Reconstr Aesthet Surg. The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. 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). These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. Patients undergoing surgery for gynecomastia should know that their scars may be visible when they are shirtless. Breast reduction surgery is considered cosmetic for all indications not listed in section I, A. outline: none; 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. } padding-right: 18px; Quality of life after breast reduction. The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability. (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) Fagerlund A, Lewin R, Rufolo G, et al. Breast and aesthetic surgery. Three review authors undertook independent screening of the search results. Statistical analysis was performed with student t-test and chi-square test. Breast reduction for symptomatic macromastia. list-style-type: upper-roman; Annu Rev Med. Nelson et al (2014a) analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Magnetic Resonance Imaging (MRI) of the Breast - Aetna Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . #closethis { American Society of Plastic Surgeons (ASPS). color: #FFF; 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. text-decoration: underline; A total of 81 patients were included in this study. color: white; Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. Flancbaum L, Choban PS. No other operation-related complications were observed. Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. 1999;103(6):1674-1681. } Narula HS, Carlson HE. This trial included all male patients who presented to the authors breast clinic who were diagnosed with primary gynecomastia, and were treated with a trial of tamoxifen 10 mg daily therapy, over a 10-year period from October 2004 to October 2015. 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. 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). Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. PDF Breast Reduction Surgery and Gynecomastia Surgery - Aetna Bertin ML, Crowe J, Gordon SM. /* aetna.com standards styles for templates */ Plastic Reconstr Surg. Gynecomastia has been classified into2 types. Ann Plast Surg. 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). A study by Glatt et al (1999) was a retrospective analysis of responses to questionnaires sent to patients who underwent reduction mammoplasty regarding physical symptoms and body image. 2007;356(5):479-485. list-style-type: decimal; OL LI { 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). Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. Other just require 500 grams no matter what your height and weight. A detailed drug history, including list of medications, an assessment of indirect or environmental exposure to estrogenic compounds, and recreational drug use. 2012;130(4):785-789. All patients underwent routine investigations to exclude secondary causes of gynecomastia. Current concepts in gynaecomastia. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. 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. Harmonic scalpel versus electrocautery in breast reduction surgery: A randomized controlled trial. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. Am J Infect Control. 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. Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. Khan SM, Smeulders MJ, Van der Horst CM. However, it is unclear if there is any evidence to support this practice. 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. Most UnitedHealthcare plans have a specific exclusion for breast reduction surgery except as required by the . Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. } padding: 15px; The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. Chadbourne EB, Zhang S, Gordon MJ, et al. The Breast: Comprehensive Management of Benign and Malignant Diseases. 1990;24(1):61-67. For individuals who received radiation treatment to the chest . No new trials were identified for this first update. 0017 - Breast Reduction Surgery and Gynecomastia Surgery, are met. Plastic Reconstr Surg. A systematic search of the published literature was performed. 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). It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. The authors concluded that gynecomastia treatment combining high-definition liposculpture to male breast tissue resection via a new, almost invisible incision allowed these researchers to achieve an athletic and natural appearance of the male pectoral area with a very low rate of complications. Grooving where the bra straps sit on the shoulder. Gonzalez FG, Walton RL, Shafer B, et al. 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. Gynecomastia may be drug-induced. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). Arlington Heights, IL: ASPS; May 2011. Breast cancer found at the time of breast reduction. 2000;106(2):280-288. Srinivasaiah N, Iwuchukwu OC, Stanley PR, et al. Does Aetna Cover Breast Reduction? | HelpAdvisor.com He Q, Zheng L, Zhuang D, et al. } Nguyen JT, Wheatley MJ, Schnur PL, et al. 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. background-color:#eee; 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. 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. 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. The authors concluded that this study was the largest to-date examining the role of tamoxifen in idiopathic gynecomastia, and these findings showed approximately 9 in every 10 men treated with tamoxifen therapy had successful resolution of their symptoms. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. 1998;26(1):61-65. CG-SURG-71 Reduction Mammaplasty - Anthem Although the BRAVO study nominally included a "control group", there was no comparison group of subjects selected from the same cohort, who were randomized or otherwise appropriately assigned to reduce bias, and treated with conservative management according to a protocol to ensure optimal conservative care. Ann Chir Plast Esthet. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. Plastic Reconstruct Surg. The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. Plast Reconstr Surg. Does Health Insurance Cover Breast Reduction Surgery? - GoodRx J Plast Reconstr Aesthet Surg. Plastic Reconstruct Surg. 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. Collis N, McGuiness CM, Batchelor AG. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. Plastic Reconstr Surg. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. 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). Reduction mammaplasty provides long-term improvement in health status and quality of life. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. A cohort study of breast cancer risk in breast reduction patients. Clinical Policy: Reduction Mammoplasty and Gynecomastia Surgery - WellCare list-style-type: decimal; Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. 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 Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. Breast hypertrophy. Subjects were compared to age-matched norms from another study cohort. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. 2017;139(6):1313-1322. 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. 1997;185(6):593-603. 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.. 1969;44(235):291-303. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. 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. Prasetyono TOH, Budhipramono AG, Andromeda I, et al. 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). font-size: 18px; 2003;111(2):688-694. 18th ed. Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. 2006;9(2):109-114. A total of 15 articles met the inclusion criteria for review. background: #5e9732; Coding This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. Level of Evidence = IV. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . .strikeThrough { 2007;36(2):497-519. Plast Reconstr Surg. 2009;7(2):114-119. .headerBar { The nipple-areola complex was re-positioned in 60 % of patients (n = 54). PDF Clinical Policy Bulletin: Cosmetic Surgery - Aetna