Fw: Aetna Insurance Policies

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From: " ilena rose " <ilena@...>

Sent: Wednesday, November 28, 2001 12:35 AM

Subject: Aetna Insurance Policies

~~~ Thanks Sandy. I've had a few questions lately on Aetna insurance.

Thanks for forwarding this for those who need it. ~~~

http://www.aetna.com/cpb/data/CPBA0142.html

Coverage Policy Bulletins

Subject: Breast Implants/Removal

Policy

Aetna U.S. Healthcare covers the removal of breast implants for

patients who meet the following selection criteria.

For patients who have undergone either cosmetic augmentation

mammoplasty or breast reconstruction following a medically necessary

mastectomy (e.g., mastectomy for breast cancer or a prophylactic

mastectomy), removal of breast implants is covered for ANY of the

following indications:

1) Breast cancer, or

2) Extruded implants, or

3) Implants complicated by recurrent infections, or

4) Implants with Baker Class IV contracture associated with severe

pain, or

5) Implants with severe contracture that interferes with mammography,

or

6) Ruptured silicone gel-filled implants.

For patients whose breast reconstruction followed a medically

necessary mastectomy (i.e., mastectomy for breast cancer or a

prophylactic mastectomy), breast implant removal is also covered for

these additional indications:

1) Baker Class III contracture, or

2) Ruptured saline implant.

Removal of ruptured saline-filled breast implants is not covered for

patients who have previously undergone cosmetic breast augmentation

mammoplasty.

If any of the above coverage criteria for removal of a breast implant

is met unilaterally, Aetna will also cover removal of the implant in

the other breast if both implants are removed at the same time.

Requests for removal of breast implants for any of the following

indications should be referred to a medical director for review:

1) Breast malposition or asymmetry;

2) Baker Class II contracture;

3) Baker Class III contracture that does not follow a medically

necessary mastectomy;

4) Removal of breast implant due to patient anxiety about developing

an autoimmune disease;

5) Implant removal for biopsy of breast mass that has not been proven

to be cancerous; or

6) Implant removal for a mastectomy or lumpectomy that can be

performed with the implant in place.

Silicone implant removal for autoimmune disease:

Aetna U.S. Healthcare does not cover ANY of the following because an

FDA panel concluded that there was no convincing evidence linking

silicone implants to the development of autoimmune disease:

1) Removal of silicone implants for autoimmune disease unless the

patient meets one or more of the selection criteria listed above

(e.g., rupture of silicone-gel filled implant, etc.);

2) IgG testing in connection with silicone implants (the development

of IgG antibodies is neither specific to silicone implants nor

indicative of autoimmune disorders).

Reinsertion of breast implants:

Although Aetna U.S. Healthcare covers the removal of breast implants

for medical indications even if the implants were originally inserted

for cosmetic purposes, Aetna will not pay for the reinsertion of new

breast implants in this situation. We will provide coverage for

insertion of initial breast implants and for the replacement of breast

implants inserted following a medically necessary mastectomy (i.e.,

mastectomy for breast cancer or a prophylactic mastectomy).

Baker Classification:

Class I

augmented breast feels soft as a normal breast

Class II

augmented breast is less soft and implant can be palpated, but is

not visible

Class III

augmented breast is firm, palpable and the implant ( or distortion )

is visible

Class IV

augmented breast is hard, painful, cold, tender, and distorted

Application to Products

Unless indicated otherwise above, this policy applies to all fully

insured Aetna U.S. Healthcare HMO, POS and PPO plans and to all other

plans, unless a specific limitation or exception exists. For

self-funded plans, consult individual plan sponsor benefit

descriptions. If there is a discrepancy between this policy and a

self-funded customer & #8217;s plan of benefits, the provisions of the

benefits plan will govern. With respect to fully insured plans and

self-funded non-ERISA (e.g., government, school boards, church) plans,

applicable state mandates will take precedence over either. Unless

otherwise specifically excluded, Federal mandates will apply to all

plans. With respect to Medicare and Medicaid members, this policy will

apply unless Medicare and Medicaid policies extend coverage beyond

this Coverage Policy Bulletin. HCFA's Coverage Issues Manual can be

found on the following website:

http://www.hcfa.gov/pubforms/06_cim/ci00.htm

Place of Service:

Outpatient or Inpatient

The above policy is based on the following references:

Chung KC, Greenfield ML, Walters M. Decision-analysis methodology in

the work-up of women with suspected silicone breast implant rupture.

Plast Reconstr Surg 1998 Sep;102(3):689-95

Cook RR, Curtis JM, Perkins LL, Hoshaw SJ. Rupture of silicone-gel

breast implants. Lancet 1998 Feb 14;351(9101):520-1

s W. Rupture of silicone-gel breast implants. Lancet 1998 Feb

14;351(9101):521

C, Dennison E. Do silicone breast implants cause connective

tissue disease? BMJ 1998 Feb 7;316(7129):403-4

Hadden WE. Silicone breast implants: a review. Australas Radiol 1998

Nov;42(4):296-302

Beekman WH, van Straalen WR, Hage JJ, et al. Imaging signs and

radiologists' jargon of ruptured breast implants. Plast Reconstr Surg

1998 Sep;102(4):1281-9

Middleton MS. Magnetic resonance evaluation of breast implants and

soft-tissue silicone. Top Magn Reson Imaging 1998 Apr;9(2):92-137

Archer RR. Breast implants. Plast Reconstr Surg 1997 Aug;100(2):555

Claman HN. Autoimmunity after silicone breast implants. Ann Allergy

Asthma Immunol 1997 Aug;79(2):89-90

Pollock H. Breast capsular contracture. Plast Reconstr Surg 1997

Nov;100(6):1619-20

Brown SL, Silverman BG, Berg WA. Rupture of silicone-gel breast

implants: causes, sequelae, and diagnosis. Lancet 1997 Nov

22;350(9090):1531-7

Chung KC, Wilkins EG, Beil RJ Jr, et al. Diagnosis of silicone gel

breast implant rupture by ultrasonography. Plast Reconstr Surg 1996

Jan;97(1):104-9

Egilman DS, Stubbs C. Evaluating the health risks of breast implants.

N Engl J Med 1996 Oct 10;335(15):1154-5; discussion 1156

Rosenbaum J. The American College of Rheumatology statement on

silicone breast implants represents a consensus. Arthritis Rheum 1996

Oct;39(10):1765

Karns ME, Cullison CA. Breast implants and connective-tissue disease.

JAMA 1996 Jul 10;276(2):101-2; discussion 103

Mogelvang C. Breast implants. Plast Reconstr Surg 1995 Jul;96(1):236

Bestler JM. Ruptured breast implant. Plast Reconstr Surg 1995

Jul;96(1):234-5

© 2000-2001 Aetna U.S. Healthcare® Inc. Coverage Policy Bulletins are

developed to assist in administering plan benefits and constitute

neither offers of coverage nor medical advice. This Coverage Policy

Bulletin contains only a partial, general description of plan or

program benefits and does not constitute a contract. Aetna U.S.

Healthcare does not provide health care services and, therefore,

cannot guarantee any results or outcomes. Participating providers are

independent contractors in private practice and are neither employees

nor agents of Aetna U.S. Healthcare or its affiliates. Treating

providers are solely responsible for medical advice and treatment of

members. This Coverage Policy Bulletin may be updated and therefore is

subject to change.

August 14, 2001