Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Surgery for Gynecomastia

Policy #:11.08.12h

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

Surgery for gynecomastia is not covered by the Company because it is considered a cosmetic service. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.
Guidelines

BENEFIT APPLICATION

Services that are cosmetic are a benefit contract exclusion for all products of 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.

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.

SURGICAL TREATMENT OF GYNECOMASTIA

Much of the focus on the treatment of gynecomastia has been on the importance of psychological and aesthetic aspects rather than functional outcomes. Treatment of gynecomastia should be directed at correcting the underlying, causative clinical condition.

Surgery for gynecomastia involves the removal of hypertrophic breast tissue and associated surrounding subcutaneous tissue. Surgery for gynecomastia that includes the use of liposuction for adipose tissue, or glandular breast tissue for unilateral or bilateral gynecomastia is rarely indicated and generally cosmetic when performed for the primary purpose of altering or improving physical appearance, and not to restore a physical, functional impairment.

COSMETIC SERVICES

Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement does not constitute improvement in physiologic function.
References


American Society of Plastic Surgeons (ASPS). ASPS recommended insurance coverage criteria for third-party payers. Gynecomastia. [ASPS Web site]. 03/2002. Available at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/insurance/Gynecomastia-Insurance-Coverage.pdf. Accessed February 5, 2018.

Artz S, Lehman JA Jr. Surgical correction of massive gynecomastia. Arch Surg.1978;113(2):199-201.

Bembo SA, Carlson HE. Gynecomastia: its features, and when and how to treat it. Cleveland Clinic Journal of Medicine.2004;71(6):511-517.

Botta SA. Alternatives for the surgical correction of severe gynecomastia. Aesthetic Plast Surg. 1998;22(1):65-70.

Braunstein GD. Diagnosis and treatment of gynecomastia. Hosp Pract. 1993;28(10A):37-46.

Braunstein GD, Anawalt BD. Epidemiology, pathophysiology, and causes of gynecomastia. 02/10/2017. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed February 2, 2018.

Braunstein GD, Anawalt BD. Management of gynecomastia. 02/10/2017. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed February 2, 2018.

Brenner P, Berger A, Schneider W, Axmann HD. Male reduction mammoplasty in serious gynecomastias. Aesthetic Plast Surg. 1992;16(4):325-330.

Donati L, Grappolini S, Ponzielli G, Colonna M, Capretti A. Surgical treatment of gynecomastia. Indications and methods. Minerva Chir. 1993;48(13-14):743-747.

Fagerlund A, Lewin R, Rufolo G, et al. Gynecomastia: A systematic review. J Plast Surg Hand Surg. 2015;49(6):311-318.

Frantz AG. Endocrine disorders of the breast. In: Wilson JD, Foster DW, Kronenberg HM, Larsen PR, eds. Williams Textbook of Endocrinology. 9th ed. Philadelphia, PA: WB Saunders Company; 1998: 886-887.

Ginkas P, Mokbel K. Management of gynecomastia: An update. [Medscape Web site]. Original 07/01/2007. Updated 08/06/07. Available at: http://cme.medscape.com/viewarticle/560809 [via subscription only]. Accessed February 5, 2018.

Glass AR. Gynecomastia. Endocrinol Metab Clin North Am. 1994;23(4):825-837.

Goes JC, Landecker A. Ultrasound-assisted lipoplasty (UAL) in breast surgery. Aesthetic Plast Surg. 2002; 26(1):1-9.

Hamer DB. Gynecomastia. Br J Surg.1975;62(4):326-329.

Kauf E. Gynecomastia in childhood. Pathological causes unusual but serious. Fortschur Med. 1998;116(35-36):23-26.

Kumar RJ, Barqawi A, Crawford ED. Adverse events associated with hormonal therapy for prostate cancer. Rev Urol. 2005;7Suppl 5:S37-S43.

Kwee RM, van den Bosch MA, El Ouamari M, et al. Contrast-enhanced breast ultrasonography reveals an unusual breast tumor in a male patient with gynecomastia. J Ultrasound Med. 2006;25(10):1347-1351.

Mahoney CP. Adolescent gynecomastia. Differential diagnosis and management. Pediatr Clin North Am.1990;37(6):1389-1404.

Neuman JF. Evaluation and treatment of gynecomastia. Am Fam Physician.1997;55(5):1835-1844, 1849-1850.

Nicolis GL, Modlinger RS, Gabrilove JL. A study of the histopathology of human gynecomastia. J Clin Endocrinol Metab.1971;32(2):173-178.

Nordt CA, DiVasta AD. Gynecomastia in adolescents. Curr Opin Pediatr. 2008;20(4):375-382. Rohrich RJ, Ha RY, Kenkel JM, et al. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plastic Reconstr Surg. 2003;111(2):909-923.

Smoot EC 3rd. Eccentric skin resection and purse-string closure for skin reduction with mastectomy for gynecomastia. Ann Plast Surg.1998;41(4):378-383.

Sonmez K, Turkyilmaz Z, Karabulut R, et al. Surgical breast lesions in adolescent patients and a review of the literature. Acta Chir Belg. 2006;106(4):400-404.

Taber's Cyclopedic Medical Dictionary. 17th ed. Philadelphia, PA: FA Davis Company; 1989: 835.

Taylor SA. Gynecomastia in children and adolescents. 11/02/2016. Up to Date. [UpToDate Web site]. http://www.uptodate.com/home/index.html. [via subscription only]. Accessed February 2, 2018.

Teimourian B, Perlman R. Surgery for gynecomastia. Aesthetic Plast Surg. 1983;7(3):155-157.





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


Cross References


Policy History

Revisions from 11.08.12h:
06/05/2019This policy has been reissued in accordance with the Company's annual review process.
04/25/2018This policy has undergone routine review, and no revisions have been made.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 05/18/2016
Version Issued Date: 05/18/2016
Version Reissued Date: 06/05/2019

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2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.