BlueCross BlueShield of Tennessee Medical Policy Manual

Mastectomy for Gynecomastia

DESCRIPTION

Gynecomastia is a benign enlargement of the male breast, either due to increased adipose tissue, glandular tissue, fibrous tissue, or a combination of all three. Bilateral gynecomastia may be associated with an underlying hormonal disorder (i.e., conditions causing either estrogen excess or testosterone deficiency such as liver disease or endocrine disorder), an adverse effect of certain drugs or obesity.

Gynecomastia may be related to specific age groups:

Treatment of gynecomastia involves consideration of the underlying cause, e.g., treatment of underlying hormonal disorder, cessation of drug therapy or weight loss. Prolonged gynecomastia causes periductal fibrosis and stromal hyalinization. Surgical removal of the breast tissue using surgical excision may be considered if conservative therapies are not effective.

While it is not necessary to carry out a thorough diagnostic investigation in every case of gynecomastia, the presence of an underlying tumor (breast or testicular) needs to be excluded.

Note: This policy does not address the use of this procedure for the mature individual with unilateral breast enlargement related to neoplasm.

POLICY

See also: Liposuction

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

SOURCES

American Academy of Family Physicians. (2012, April). Gynecomastia. Retrieved September 22, 2015 from http://www.aafp.

American College of Radiology. (2014). ACR appropriateness criteria evaluation of the symptomatic male breast. Retrieved May 31, 2017 from the National Guideline Clearinghouse (NGC: 010653).

American Society of Plastic Surgeons. ASPS recommended insurance coverage criteria for third-party payers. Gynecomastia. Retrieved May 31, 2017 from https://www.plasticsurgery.org/Documents/Health-Policy/Positions/Gynecomastia_ICC.pdf.

BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2017). Surgical treatment of bilateral gynecomastia (7.01.13). Retrieved May 31, 2017 from BlueWeb. (4 articles and/or guidelines reviewed)

Fricke, A., Lehner, G., Stark, G., & Penna. V. (2017). Long-term follow-up of recurrence and patient satisfaction after surgical treatment of gynecomastia. Aesthetic Plastic Surgery, 41 (3), 491-498. Abstract retrieved May 31, 2017 from PubMed database.

Wisconsin Physicians Services Insurance Corporation (2017, January) Local Coverage Determination (LCD) for Cosmetic and reconstructive surgery (L34698). Retrieved May 31, 2017 from https://www.cms.gov.

ORIGINAL EFFECTIVE DATE:  1/1997

MOST RECENT REVIEW DATE:  7/13/2017

ID_BT

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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