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Coverage criteria policies

Gynecomastia surgery

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for gynecomastia surgery.

Coverage

Gynecomastia surgery is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

For all requests, documentation must include all of the following: Grade of gynecomastia, length of time present, underlying conditions tested for and results of testing, treatments attempted and results of treatments.

  1. Malignancy is suspected; or
  2. Pubertal (adolescent) onset gynecomastia when all of the following criteria are met:
    1. The condition has been present for at least two years.
    2. Clinical documentation indicates the presence of glandular breast tissue on physical exam.
    3. The degree of gynecomastia is classified as Grade III or IV per the American Society of Plastic Surgeons classification system listed below.
    4. There is persistent breast pain directly related to gynecomastia.
    5. The use of potentially gynecomastia inducing drugs or substances has been identified and discontinued (if applicable or medically appropriate) for at least 6 months without spontaneous regression of the condition.
    6. The presence of an underlying, treatable pathological condition has either been ruled out via appropriate laboratory testing or has been identified and treated without regression of gynecomastia for at least one year before surgery is considered.
  3. Post-pubertal onset gynecomastia when all of the following criteria are met:
    1. The condition has been present for at least one year.
    2. Clinical documentation indicates the presence of glandular breast tissue on physical exam.
    3. The degree of gynecomastia is classified as Grade III or IV per the American Society of Plastic Surgeons classification system listed below.
    4. There is persistent breast pain directly related to gynecomastia.
    5. The use of potentially gynecomastia inducing drugs or substances has been identified and discontinued (if applicable or medically appropriate) for at least 6 months without spontaneous regression of the condition.
    6. The presence of an underlying, treatable pathological condition has either been ruled out via appropriate laboratory testing or has been identified and treated without regression of gynecomastia for at least six months before surgery is considered.

Indications that are not covered

  1. Gynecomastia surgery to improve the appearance of the male breast or to alter the contours of the chest wall is considered cosmetic.
  2. Surgery to remove excess adipose (fat) tissue (pseudogynecomastia) is considered cosmetic.

Definitions

Classification system for gynecomastia per the American Society of Plastic Surgeons

  • Grade I: Small breast enlargement with localized button of tissue around the areola
  • Grade II : Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest
  • Grade III : Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present
  • Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast.

Gynecomastia is the presence of an abnormal development of glandular breast tissue in males. Breast development may be bilateral or unilateral.

Pathological gynecomastia refers to breast enlargement caused by disease, conditions, medications, or illicit drugs or alcohol that decrease the production or activity of testosterone, or that increase the production or activity of estrogen. In some cases, the cause is unknown. Examples of specific conditions that are associated with gynecomastia include but are not limited to:

  • Decreased testosterone production/activity (hypogonadism): Klinefelter’s syndrome, congenital hypogonadism, hermaphroditism, testicular trauma, renal failure, hyperthyroidism, and malnutrition.
  • Increased estrogen production/activity: hormone production by certain cancers or tumors, chronic liver disease, malnutrition, hyperthyroidism, adrenal tumors, and familial gynecomastia.
  • Drugs: ingestion of any of a variety of prescription or non- prescription drugs such as exogenous estrogens, anti-androgens 5 alpha-reductase inhibitors, spironolactone, ketoconazole, cimetidine, ranitidine, several chemotherapy drugs, tricyclic antidepressants, antipsychotics, natural products containing phtyoestrogens, anabolic steroids, heroin, alcohol and marijuana. Medical treatment of pathological gynecomastia depends upon the cause.

Pseudogynecomastia: In true gynecomastia, the breast enlargement is due to glandular breast tissue growth. In pseudogynecomastia, the breast enlargement is due to the accumulation of fat. Pseudogynecomastia often affects obese boys and men. It can be treated by weight loss or liposuction.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

19300

Mastectomy for gynecomastia

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. American Society of Plastic Surgeons (2004). Practice Parameters-Gynecomastia. Retrieved August 1, 2016 from https://www.plasticsurgery.org
  2. Anawalt, B.D. (2016). Gynecomastia. Endocrinology: Adult and Pediatric. Seventh Edition. Retrieved from https://www.clinicalkey.com
  3. Anders Fagerlund, Richard Lewin, Guglielmo Rufolo, Anna Elander, Fabio Santanelli di Pompeo & Gennaro Selvaggi (2015) Gynecomastia: A systematic review, Journal of Plastic Surgery and Hand Surgery, 49:6, 311-318.
  4. Braunstein, G. Clinical features, diagnosis, and evaluation of gynecomastia. In: UpToDate, Matsumodo, A. (Ed), UpToDate, Waltham, MA. (Accessed on August 17, 2017).
  5. Braunstein, G. Management of gynecomastia. In: UpToDate. Matsumodo, A. (Ed). UpToDate, Waltham, MA. (Accessed on August 17, 2017).
  6. Carlson, H.E. (2011). Approach to the Patient with Gynecomastia. The Journal of Clinical Endocrinology & Metabolism. 96:1, 15-21.
  7. ECRI Institute. (2014). Liposuction for Breast Reduction Surgery. Plymouth Meeting, PA: ECRI Institute
  8. Fagerlund, A., Lewin, R. Guglielmo, R., Elander A., Santanelli di Pompeo, F. and Selvaggi, G. (2015). Gynecomastia: A systematic review. Journal of Plastic Surgery and Hand Surgery, 49:6, 311-318.
  9. Hayes, Inc. Hayes HealthTechnology Brief. Mastectomy for Gynecomastia. Lansdale, PA: Hayes, Inc.; July, 2010. Reviewed July, 2012/Archived Aug, 2013.
  10. Johnson, R. and Murad, M. H. (2009). Gynecomastia: Pathophysiology, Evaluation, and Management. Mayo Clinic Proceedings. 84(11): 1010-1015.
  11. Satpathy, H. K. (2017). Gynecomastia. Ferri’s Clinical Advisor 2018. Retrieved from https://www.clinicalkey.com

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Policy activity

  • 10/31/1994 - Date of origin
  • 01/01/2017 - Effective date
Review date
  • 08/2017

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