Medicare Advantage

Medical Policy

Title:

Surgery for Gynecomastia

Policy #:

MA11.110a

Policy

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 policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.

MEDICALLY NECESSARY

Mastectomy with nipple preservation for gynecomastia or reduction mammoplasty for gynecomastia is considered medically necessary and, therefore, covered when all of the following criteria are met:

Unilateral or bilateral gynecomastia Grade III or IV as defined by the American Society of Plastic Surgeons' Gynecomastia Scale or abnormal breast development with redundancy.

Gynecomastia persists more than 3 to 4 months after pathological causes are ruled out.
Gynecomastia persists after 3 to 4 months of unsuccessful medical treatment for pathological gynecomastia.

There is pain or tenderness directly related to the breast tissue which has a clinically significant impact upon activities of daily living.
The clinical symptoms are refractory to a trial of analgesics or anti-inflammatory agents.
There are significant clinical manifestations when the excessive breast weight adversely affects the supporting structures of the shoulders, neck, and trunk.

NOT MEDICALLY NECESSARY

Mastectomy with nipple preservation or reduction mammoplasty, either unilateral or bilateral, as a first line treatment for gynecomastia is condidered not medically necessary and, therefore, not covered.

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.

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% 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.

Breast reduction or surgical mastectomy for gynecomastia, either unilateral or bilateral, is not a 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 40%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: 07/11/2021). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=35090&DocID=L35090. Accessed January 15, 2025.

Coding

CPT Procedure Code Number(s)

19300

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

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA11.110a:

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.
01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
09/06/2023	This policy has been reissued in accordance with the Company's annual review process.
12/19/2022	This version of the policy will become effective 12/19/2022. This was updated to incorporate additional medical criteria per Novitas Solutions' LCD L35090: Cosmetic and Reconstructive Surgery.

Revisions From MA11.110:

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.
06/05/2019	This policy has been reissued in accordance with the Company's annual review process.
04/25/2018	This policy has undergone a routine review, and no revisions have been made.
03/29/2017	The policy has been reviewed and reissued to communicate the Company’s continuing position on surgery for gynecomastia.
05/18/2016	This 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:

12/19/2022

Version Issued Date: