Medical Policies - Surgery


Surgical Treatment of Gynecomastia

Number:SUR716.017

Effective Date:06-15-2018

Coverage:

*CAREFULLY CHECK STATE REGULATIONS AND/OR THE MEMBER CONTRACT*

Surgical treatment of gynecomastia by any method (including, but not limited to, subcutaneous and/or suction lipectomy, liposuction, or lipoplasty assisted gynecomastia mastectomy), is considered not medically necessary, as gynecomastia does not result in functional impairment. This determination applies regardless of the underlying condition including, but not limited to, an underlying hormonal disorder, obesity, adolescence and other age related breast tissue enlargement symptoms, and/or the reversible side effects of drug treatment.

Mastectomy, reduction mammaplasty, or mastopexy in male patients are considered to be primarily done to alter physical appearance, and are therefore considered not medically necessary (see NOTE 1).

NOTE 1: This policy does not address the use of mastectomy for a male patient to remove breast tissue following a biopsy confirming a malignancy.

NOTE 2: Regarding Cosmetic Services: Determination of benefit coverage for procedures considered to be cosmetic is based on how a member's benefit contract defines cosmetic services and their eligibility for benefit coverage. Determination of coverage eligibility for the surgical treatment of gynecomastia may require consideration of whether or not such surgery would be considered either essentially cosmetic in nature or reconstructive. Contractual definitions of the scope of reconstructive services that may be eligible for coverage vary. Determinations of whether a proposed therapy would be considered reconstructive or cosmetic should always be interpreted in the context of the specific benefits language.

Description:

Gynecomastia is a benign enlargement of the male breast, either due to increased adipose tissue, glandular tissue, fibrous tissue, or a combination of all 3.

Background

Bilateral gynecomastia may be associated with any of the following:

An underlying hormonal disorder (i.e., conditions causing either estrogen excess or testosterone deficiency such as liver disease or an endocrine disorder);

An adverse effect of certain drugs (including, but not limited to steroids, chemotherapy, etc.);

Obesity; or

Related to specific age groups:

o Neonatal gynecomastia, related to action of maternal or placental estrogens;

o Adolescent gynecomastia, which consists of transient, bilateral breast enlargement, which may be tender; or

o Gynecomastia of aging, related to the decreasing levels of testosterone and relative estrogen excess.

Treatment of gynecomastia involves consideration of the underlying cause. For example, treatment of the underlying hormonal disorder, cessation of drug therapy, or weight loss may all be effective therapies. Gynecomastia may also resolve spontaneously, and adolescent gynecomastia may resolve with aging.

Prolonged gynecomastia causes periductal fibrosis and stromal hyalinization, which prevent regression of the breast tissue. Surgical removal of the breast tissue, using surgical excision or liposuction, may be considered if the conservative therapies above are not effective or possible and the gynecomastia does not resolve spontaneously or with aging.

Regulatory Status

Removal of the breast tissue is a surgical procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration.

Rationale:

This policy was originally created in 1990 and has regularly been updated with literature reviews. The most recent literature review was conducted through May 24, 2017. The following is a summary of the literature.

As previously noted, coverage eligibility for treatment of gynecomastia is largely a contract/benefit issue related to the distinction between cosmetic and reconstructive services. The surgical procedure may involve surgical excision (i.e., mastectomy). More recently, liposuction has been used. (1, 2) In some instances, adolescent gynecomastia may be reported as tender or painful, and the presence of these symptoms may be presented as a rationale for the medical necessity of surgical treatment. However, the pain associated with adolescent gynecomastia is typically self-limiting or responds to analgesic therapy.

To demonstrate improvement in health outcomes, controlled trials are needed that report clinically important outcomes such as improvement in functional status. No such trials were identified through literature search. A systematic review published in 2015 included 14 studies on the treatment of gynecomastia. (3) None was randomized, all were judged to be at high risk of bias, and the body of evidence was determined to be of very low quality by GRADE criteria, which is a method of accessing the certainty of evidence and the strength of recommendations in healthcare.

Ongoing and Unpublished Clinical Trials

A search of ClinicalTrials.gov in January 2017 did not identify any ongoing or unpublished trials that would likely influence this review.

Practice Guidelines and Position Statements

American Society of Plastic Surgeons (ASPS)

The ASPS issued practice criteria for third-party payers in 2002. (4) The ASPS classified gynecomastia using the following scale, which was “adapted from the McKinney and Simon, Hoffman and Kohn scales”:

Grade I: Small breast enlargement with localized button of tissue that is concentrated 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 distinct from the chest with skin redundancy present.

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

According to the ASPS, in adolescents, surgical treatment for unilateral or bilateral grade II or III gynecomastia may be appropriate if the gynecomastia persists for more than 1 year after pathologic causation is ruled out (or 6 months if grade IV) and continues after 6 months if medical treatment is unsuccessful. In adults, surgical treatment for unilateral or bilateral grade III or IV gynecomastia may be appropriate if the gynecomastia persists for more than 3 or 4 months after pathologic causation is ruled out and continues after 3 or 4 months of medical treatment that is unsuccessful. The ASPS also indicated that surgical treatment of gynecomastia may be appropriate when distention and tightness cause pain and discomfort.

Summary of Evidence

For individuals with bilateral gynecomastia who receive surgical treatment, the evidence includes case series. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related morbidity. Because there are no randomized controlled trials on surgical treatment of gynecomastia, it is not possible to determine whether surgical treatment improves symptoms or functional impairment. Conservative therapy should adequately address any physical pain or discomfort, and gynecomastia does not typically cause functional impairment. The evidence is insufficient to determine the effect of the technology on health outcomes.

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

CODING:

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

15839, 19300

HCPCS Codes

None

ICD-9 Diagnosis Codes

Refer to the ICD-9-CM manual

ICD-9 Procedure Codes

Refer to the ICD-9-CM manual

ICD-10 Diagnosis Codes

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.

A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.

References:

1. 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):909-23; discussion 24-5. PMID 12560721

2. Goes JC, Landecker A. Ultrasound-assisted lipoplasty (UAL) in breast surgery. Aesthetic Plast Surg. 2002; 26(1):1-9. PMID 11891589

3. Fagerlund A, Lewin R, Rufolo G, et al. Gynecomastia: A systematic review. J Plast Surg Hand Surg. Dec 2015; 49(6):311-8. PMID 26051284

4. American Society of Plastic Surgeons. ASPS Recommended Insurance Coverage Criteria for Third-Party Payers (March 2002). Available at: <http://www.plasticsurgery.org> (accessed March 18, 2015).

5. Surgical Treatment of Bilateral Gynecomastia. Chicago, Illinois: Blue Cross Blue Shield Association (February 2017) Surgery 7.01.13.

Policy History:

Date Reason
6/15/2018 Reviewed. No changes.
7/15/2017 Document updated with literature review. Coverage unchanged.
7/15/2016 Reviewed. No changes.
6/1/2015 Document updated with literature review. Coverage unchanged.
11/15/2014 Reviewed. No changes.
11/1/2013 Document updated with literature review. Coverage unchanged. Title changed from “Mastectomy for Gynecomastia”.
8/1/2008 Policy reviewed without literature review; new review date only. This policy is no longer scheduled for routine literature review and update.
7/15/2006 Revised/updated entire document
8/1/1999 Revised/updated entire document
5/1/1996 Medical policy number changed
5/1/1990 New medical document

Archived Document(s):

Title:Effective Date:End Date:
Surgical Treatment of Gynecomastia07-15-201706-14-2018
Surgical Treatment of Gynecomastia07-15-201607-14-2017
Surgical Treatment of Gynecomastia06-01-201507-14-2016
Surgical Treatment of Gynecomastia11-15-201405-31-2015
Surgical Treatment of Gynecomastia11-01-201311-14-2014
Mastectomy for Gynecomastia08-01-200810-31-2013
Mastectomy for Gynecomastia07-15-200607-31-2008
Mastectomy for Gynecomastia08-01-199907-14-2006
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