Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Surgery for Gynecomastia
Policy #:MA11.110

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

MEDICALLY NECESSARY

Mastectomy with nipple preservation for gynecomastia or reduction mammoplasty for gynecomastia is considered medically necessary and, therefore, covered for any of the following:
  • Individuals with gynecomastia Grade III or IV as defined by The American Society of Plastic Surgeons' Gynecomastia Scale; OR
  • Individuals with abnormal breast development with redundancy.

COSMETIC

Mastectomy with nipple preservation for gynecomastia or reduction mammoplasty for gynecomastia that do not meet the medical necessity criteria listed in this policy are considered cosmetic services. Services that are cosmetic are not covered by the Company because cosmetic services are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the professional provider's office, hospital, nursing home, home health agency, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be made available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

All requests for reconstructive breast surgery require review by the Company and must include documentation. This documentation is to include, but is not limited to, color photographs, a letter of medical necessity from the provider, documentation from the individual's medical records regarding previous treatment, and other professional provider's reports.
Policy Guidelines

THE AMERICAN SOCIETY OF PLASTIC SURGEONS' GYNECOMASTIA SCALE:

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 indistinct from the chest with skin redundancy present.

Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, mastectomy with nipple preservation for gynecomastia or reduction mammoplasty for gynecomastia is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as cosmetic are not eligible for coverage or reimbursement by the Company.

Description

Gynecomastia is a benign condition caused by overgrowth of the glandular component of the male breast. Enlargement of the breast may be associated with various physiological, pathological, or pharmacological causes. Gynecomastia develops primarily due to an altered estrogen-androgen balance or a heightened breast sensitivity to a normally circulating estrogen level; it can be unilateral or bilateral. The condition is common and occurs in more than 50 percent of males during puberty and more than 30 percent of healthy young and middle-aged fertile men; these figures increase with age and adiposity. Most cases of minimal subareolar pubertal-onset gynecomastia usually regress as puberty progresses. In some instances, adolescent gynecomastia may be reported as tender or painful; however, this pain is normally self-limiting or responds to analgesic therapy. Typically no functional impairment is associated with gynecomastia.

Breast reduction or surgical mastectomy for gynecomastia, either unilateral or bilateral, is not first line treatment. Medical therapy should be aimed at correcting any reversible causes (e.g. drug discontinuance). Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management due to gynecomastia.

There are several other types of gynecomastia:
  • Mixed gynecomastia involves the presence of both fat and glandular tissue.
  • Pathological gynecomastia is usually attributed to both estrogen excess and androgen deficiency. These causes may be associated with medication therapy, endocrine abnormalities, or other disease entities.
  • Physiologic gynecomastia is the result of alterations in estrogen/androgen balances, and the increased sensitivity of breast tissue to normal estrogen levels; this type of gynecomastia may occur during periods of male hormonal changes.
  • Pseudogynecomastia is the enlargement of male breasts secondary to fat accumulation.
  • Pubertal gynecomastia is a relatively common condition, affecting upwards of forty percent of males aged 10 to 16 years of age. It usually resolves with aging.
    References

    Novitas Solutions, Inc.. Local Coverage Determination (LCD). L35090: Cosmetic and Reconstructive Surgery. [Novitas Solutions Web site]. Original: 10/01/2015. (Revised: 11/07/2019). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35090&ver=69&Date=03%2f24%2f2020&SearchType=Advanced&DocID=l35090&bc=KAAAAAgAAAAA&. Accessed March 24, 2020.


    Coding

    Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

    The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

    In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

    The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

19300


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N62 Hypertrophy of breast


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements

Gynecomastia is a male condition, therefore CPT code 19300 should be reported for male individuals only. This code is reported for excision of moderate amount of gynecomastia involving subareolar and nearby tissue.





Policy History

Revisions from MA11.110:
06/03/2020The policy has been reviewed and reissued to communicate the Company’s continuing position on Surgery for Gynecomastia.
06/05/2019This policy has been reissued in accordance with the Company's annual review process.
04/25/2018This policy has undergone a routine review, and no revisions have been made.
03/29/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on surgery for gynecomastia.
05/18/2016This policy will become effective 5/18/2016. This policy has been developed to communicate Company's coverage position for Surgery for Gynecomastia.




Version Effective Date: 05/18/2016
Version Issued Date: 05/18/2016
Version Reissued Date: 06/03/2020