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Surgery for Gynecomastia
11.08.12i

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.

MEDICALLY NECESSARY

Mastectomy or reduction mammoplasty for the treatment of gynecomastia is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • ​Age is either:
    • ​18 years or older, or
    • Under 18 years old, but 18 months after the end of puberty (defined as having achieved Tanner Stage 5)
  • ​Gynecomastia is classified as Grade II or higher, per the American Society of Plastic Surgeons classification.
  • The individual has persistent pain or discomfort directly related to the breast enlargement, despite a 3-month trial of analgesics (unless contraindicated).
  • Symptoms have a clinically significant impact upon activities of daily living.
  • Glandular breast tissue is documented by physical exam, biopsy, and/or imaging.
  • Good quality preoperative color photographs (anterior and lateral views) verify the exam findings documented in the medical record.
  • Breast cancer is excluded by exam or imaging.
  • An appropriate medical evaluation was completed looking for secondary causes (e.g., pathological or pharmacological causes). If a secondary cause was found, gynecomastia and related symptoms persist for 6-months after nonsurgical treatment (e.g., discontinuation of a known causative agent, when medically appropriate).
COSMETIC

Mastectomy or reduction mammoplasty for the treatment of gynecomastia for any of the following indications is considered a cosmetic service:
  • when performed solely to improve appearance of the breast or to alter contours of the chest wall
  • when performed solely to treat psychological or psychosocial complaints
  • removal of fatty tissue alone (i.e., pseudogynecomastia)
Services that are cosmetic are a benefit contract exclusion for most products of the Company. Therefore, they are not eligible for reimbursement consideration.

NOT MEDICALLY NECESSARY

Mastectomy or reduction mammoplasty for the treatment of gynecomastia for any other indication is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the treatment of illness or injury.

EXPERIMENTAL/INVESTIGATIONAL

Liposuction or ultrasonically assisted liposuction (suction lipectomy) as a sole method of treatment for gynecomastia is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

Guidelines

TANNER STAGES OF PUBERTY DEVELOPMENT IN MALES

  • ​Stage 1: Basal growth; no penile or testicular enlargement; no pubic hair
  • Stage 2: Basal growth continues; minimal pubic hair; slight testicular enlargement
  • Stage 3: First growth spurt; emergence of pubic hair over pubis; continued testicular enlargement; penis lengthens; gynecomastia common
  • Stage 4: Rapid growth rate; pubic hair distribution spreads; continued penis (length and girth) and testicular enlargement; axillary hair growth; voice deepens
  • Stage 5: Usually achieved maximum height; pubic hair distribution of adult; facial hair development begins

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.

PATHOLOGICAL CAUSES OF GYNECOMASTIA

Pathological causes of gynecomastia include, but are not limited to, the following:

  • Breast cancer
  • ​​Endocrine disorders (e.g., hyperthyroidism, excess estrogen)​
  • Hypogonadism
  • Metabolic disorders
  • ​​​Neoplasms (e.g., prolactinoma, hyperprolactinemia)

PHARMACOLOGICAL CAUSES OF GYNECOMASTIA

Pharmacological causes of gynecomastia include, but are not limited to, the following:

  • Anabolic steroids
  • Antiretroviral agents​
  • Chemotherapeutic agents
  • Chlorpromazine
  • Cimetidine
  • Clomiphene
  • Digitalis
  • Herbal remedies
  • Marijuana​
  • Methadone

BENEFIT APPLICATION


Subject to the terms and conditions of the applicable benefit contract, mastectomy or reduction mammoplasty for the treatment of gynecomastia ​is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

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

Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

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% of males during puberty and more than 30% 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 40% 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

Abdelrahman I, Steinvall I, Mossaad B, et al. Evaluation of glandular liposculpture as a single treatment for grades I and II gynaecomastia. Aesthetic Plast Surg. 2018;42(5):1222-1230.

American Society of Plastic Surgeons (ASPS). ASPS recommended insurance coverage criteria for third-party payers. Gynecomastia. [ASPS Web site]. 03/2002 (Affirmed 2015). Available at: https://www.plasticsurgery.org/documents/Health-Policy/Positions/Gynecomastia_ICC.pdf. Accessed January 15, 2025. ​​

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. Cleve Clin J Med. 2004;71(6):511-517.​

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

Bowers SP, Pearlman NW, McIntyre RC Jr., et al. Cost-effective management of gynecomastia. Am J Surg. 1998;176:638-641.

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

Braunstein GD, Anawalt BD. Clinical features, diagnosis, and evaluation of gynecomastia in adults. 04/26/2023. Up to Date. [UpToDate Web site]. Available at: https://www.uptodate.com/contents/clinical-features-diagnosis-and-management-of-klinefelter-syndrome?search=gynecomastia&source=search_result&selectedTitle=5~150&usage_type=default&display_rank=5 [via subscription only]. Accessed January 15, 2025.

Braunstein GD, Anawalt BD. Epidemiology, pathophysiology, and causes of gynecomastia. 04/25/2023. Up to Date. [UpToDate Web site]. Available at: https://www.uptodate.com/contents/epidemiology-pathophysiology-and-causes-of-gynecomastia?search=gynecomastia&source=search_result&selectedTitle=4~150&usage_type=default&display_rank=4#H1 [via subscription only]. Accessed January 15, 2025.

Braunstein GD, Anawalt BD. Management of gynecomastia. 05/10/2021. Up to Date. [UpToDate Web site]. Available at: https://www.uptodate.com/contents/management-of-gynecomastia?search=gynecomastia&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3#H23 [via subscription only]. Accessed January 15, 2025.​

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

Colombo-Benkmann M, Buse B, Stern J, et al. Indications for and results of surgical therapy for male gynecomastia. Am J Surg. 1999;178:60-63.

Courtiss EH. Gynecomastia: Analysis of 159 patients and current recommendations for treatment. Plast Reconstr Surg. 1987;79:740-753.

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.

Gasperoni C, Salgerello M, Gasperoni P. Technical refinements in surgical treatment of gynecomastia. Ann Plast Surg. 2000;44:455-458.

Ginkas P, Mokbel K. Management of gynecomastia: An update. Int J Clin Pract. 2007;61(7):1209-1215.

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.

Kanakis GA, Nordkap L, Bang AK, et al. EAA clinical practice guidelines-gynecomastia evaluation and management. Andrology. 2019;7(6):778-793.
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;7(Suppl 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.

Liu C, Tong Y, Sun F, et al. Endoscope-assisted minimally invasive surgery for the treatment of glandular gynecomastia. Aesthetic Plast Surg. 2022;46(6):2655-2664.

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

McGrath MH, Mukerji S. Plastic surgery and the teenage patient. J Pediatr Adolesc Gynecol. 2000;13:105-118.
 
Morselli PG. “Pull-through”: a new technique for breast reduction in gynecomastia. Plast Reconstr Surg. 1996;97:450-454. 

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.

Novitas Solutions, Inc. Local Coverage Article (LCA). Billing and Coding: Cosmetic and Reconstructive Surgery (A56587). 10/01/2024. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=56587​. Accessed January 15, 2025.

Novitas Solutions, Inc. Local Coverage Determination (LCD). Cosmetic and Reconstructive Surgery (L35090). 07/11/2021. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=35090. Accessed January 15, 2025.

Nuzzi LC, Firriolo JM, Pike CM, et al. The effect of surgical treatment for gynecomastia on quality of life in adolescents. J Adolesc Health. 2018;63(6):759-765.

Pensler JM, Silverman BL, Sanghavi M, et al. Estrogen and progesterone receptors in gynecomastia. Plast Reconstr Surg. 106:1011-1013.

Prasetyono TOH, Budhipramono AG, Andromeda I. Liposuction assisted gynecomastia surgery with minimal periareolar incision: a systematic review. Aesthetic Plast Surg. 2022;46(1):123-131.

Rohrich RJ, Ha RY, Kenkel JM, et al. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg. 2003;111(2):909-923; discussion 924-925.

Sher ES, Migeon CJ, Berkovitz GD. Evaluation of boys with marked breast development at puberty. Clin Pediatr. 1998;37:367-371.
 
Simon BE, Hoffman S, Kahn S. Classification and surgical correction of gynecomastia. Plast Reconstr Surg. 1973;51:48-52. 

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. 06/10/2022. Up to Date. [UpToDate Web site]. Available at: https://www.uptodate.com/contents/gynecomastia-in-children-and-adolescents?search=gynecomastia&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H27397681 [via subscription only]. Accessed ​January 15, 2025.

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

Coding

CPT Procedure Code Number(s)
19300

THE FOLLOWING CODE IS USED TO REPRESENT REDUCTION MAMMOPLASTY FOR TREATMENT OF GYNCECOMASTIA:

19318

EXPERIMENTAL/INVESTIGATIONAL
​
15877​
ICD - 10 Procedure Code Number(s)
N/A
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


Policy History

Revisions From 11.08.12i:
​03/04/2026
​This policy has been reissued in accordance with the Company's annual review process. ​
​​04/02/2025
​This policy has been reissued in accordance with the Company's annual review process. 
​​06/12/2024
​This policy has been reissued in accordance with the Company's annual review process. 
01/01/2024This version of the policy will become effective 01/01/2024.

This policy was updated to communicate the Company's Medically Necessary coverage criteria for surgery of gynecomastia.​

The following CPT Code was added as Medically Necessary to represent reduction mammoplasty for the treatment of gynecomastia: 19318

The following CPT Code was added as Experimental/Investigational: 15877

Revisions From 11.08.12h:
11/30/2022The policy has been reviewed and reissued to communicate the Company’s continuing position on Surgery for Gynecomastia.​​
​06/16/2021
​This policy has been reissued in accordance with the Company's annual review process.
​06/03/2020
​The 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 routine review, and no revisions have been made.

Effective 10/05/2017 this policy has been updated to the new policy template format.
1/1/2024
12/29/2023
3/4/2026
11.08.12
Medical Policy Bulletin
Commercial
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.