Mastectomy for Gynecomastia
DESCRIPTION
Gynecomastia, enlargement of the male breast, occurs at times of male hormonal change during infancy, adolescence and old age. Mastectomy for gynecomastia is a surgical procedure performed to remove breast glandular tissue from a male with enlarged breasts.
Gynecomastia can be caused by medications, physiologic states, and medical conditions, which alter the balance of androgen and estrogen. Approximately 40-65% of boys develop some degree of gynecomastia during puberty. This physiological pubertal form of gynecomastia usually resolves spontaneously within 2 years and rarely requires hormonal or surgical treatment. Small swellings (less than 4 cm in diameter) resolve within 3 years without therapy in 90% of these cases. Enlargement sufficient to cause embarrassment and social disability occurs in fewer than 10% of those affected by puberty related gynecomastia. While it is not necessary to carry out a thorough diagnostic investigation in every case of gynecomastia, the presence of an underlying tumor (breast and testicular) needs to be excluded.
This policy does not address the use of this procedure for the mature man with unilateral breast enlargement related to neoplasm.
POLICY
Mastectomy for gynecomastia in a male may be considered medically necessary if all of the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Mastectomy for gynecomastia for the treatment of the following conditions including but not limited to breast enlargement from obesity or from drug treatment that can be discontinued, or removal of fatty tissue alone is considered cosmetic.
MEDICAL APPROPRIATENESS
Mastectomy for gynecomastia in a male is considered medically appropriate if ALL of the following criteria are met:
Gynecomastia has persisted longer than three (3) years after the documented initial physician evaluation
Gynecomastia is striking (greater than 4 cm in diameter) and causes serious emotional disturbance
The tissue to be removed is glandular not fatty tissue verified by required histologic examination of the tissue removed
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
SOURCES
American Academy of Family Physicians. (2006, December). Gynecomastia: When Breast Form in Males. Retrieved April 20, 2007 from http://familydoctor.org/handouts/080.html.
Bowers, S. P., Pearlman, N. W., McIntyre, R. C., Finlayson, C. A., & Huerd, S. (1998). Cost-effective management of gynecomastia. American Journal of Surgery, 176 (6): 638-641. Abstract retrieved August 17, 1999 from PubMed database.
Bullmann, C., & Jockenhovel, F. (1998). Gynecomastia in men. Fortschritte Der Medizin, 116 (35-36): 18-22. Abstract retrieved August 17, 1999 from PubMed database.
Colombo-Benkmann, M., Buse, B., Stern, J., & Herfarth, C. (1999). Indications for and results of surgical therapy for male gynecomastia. American Journal of Surgery, 178 (1): 60-63. Abstract retrieved March 29, 2001 from PubMed database.
Greydanus, D. E., Matytsina, L., & Gains, M. (2006). Breast disorders in children and adolescents. Primary Care: Clinics in Office Practice, 33 (2), 455-502.
Kauf, E. (1998). Gynecomastia in childhood. Pathological causes unusual but serious. Fortschritte Der Medizin, 116 (35-36): 23-26. Abstract retrieved August 17, 1999 from PubMed database.
Sher, E. S., Migeon, C. J., & Berkovitz, G. D. (1998). Evaluation of boys with marked breast development at puberty. Clinical Pediatrics (Philadelphia), 37 (6): 367-371. Abstract retrieved August 17, 1999 from PubMed database.
ORIGINAL EFFECTIVE DATE: 1/1/1997
MOST RECENT REVIEW DATE: 6/30/2009
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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