Mastectomy for Gynecomastia
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:
Neonatal gynecomastia, related to action of maternal or placental estrogens
Adolescent gynecomastia, which consists of transient, bilateral breast enlargement, which may be tender
Gynecomastia of aging, related to the decreasing levels of testosterone and relative estrogen excess
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.
Mastectomy for gynecomastia 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, breast enlargement from drug treatment that can be discontinued, or removal of fatty tissue alone is considered cosmetic.
Mastectomy for gynecomastia 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 (preoperatively by biopsy)
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
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.
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. (2:2018). Surgical treatment of bilateral gynecomastia (7.01.13). Retrieved May 15, 2018 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 (2018, January) Local Coverage Determination (LCD) for Cosmetic and reconstructive surgery (L34698). Retrieved May 15, 2018 from https://www.cms.gov.
ORIGINAL EFFECTIVE DATE: 1/1997
MOST RECENT REVIEW DATE: 7/12/2018
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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