Mastectomy for Gynecomastia
DESCRIPTION
Gynecomastia is a benign enlargement of the male breast, either due to increased adipose tissue, glandular tissue, fibrous tissue, or a combination of the three. Bilateral gynecomastia in adult males may be associated with an underlying hormonal disorder (i.e., conditions causing either estrogen excess or testosterone deficiency such as liver disease or endocrine disorder), an adverse effect of certain drugs or obesity. Pubertal gynecomastia is a common condition with an overall incidence of 38 percent in males 10-16 years of age, increasing to 65 percent at age 14, and dropping to 14 percent in 16-year-old males. Pubertal gynecomastia often regresses spontaneously in six months and 90 percent resolve within three years. An increase in estradiol concentration, lagging free testosterone production, and increased tissue sensitivity to normal male levels of estrogen are possible causes of gynecomastia in adolescents.
Treatment of gynecomastia involves consideration of the underlying cause, e.g., treatment of underlying hormonal disorder, cessation of drug therapy or weight loss. The grade of breast enlargement is taken into consideration. Prolonged gynecomastia causes periductal fibrosis and stromal hyalinization. Surgical removal of the breast tissue using surgical excision may be considered if conservative therapies are not effective.
While it is not necessary to carry out a thorough diagnostic investigation in every case of gynecomastia, the presence of an underlying tumor (breast or testicular) needs to be excluded.
Note: This policy does not address the use of this procedure for the mature individual with unilateral breast enlargement related to neoplasm.
POLICY
Mastectomy for gynecomastia may be considered medically necessary if all the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Mastectomy for gynecomastia for the treatment of the following conditions, including but not limited to, breast enlargement from obesity, breast enlargement from drug treatment that can be discontinued, or removal of fatty tissue alone is considered cosmetic.
MEDICAL APPROPRIATENESS
Mastectomy for gynecomastia is considered medically appropriate when ANY ONE of the following are met:
Adolescent males (14-17 years old) when ALL the following criteria are met:
Functional Impairment (e.g., chronic skin irritation, pain, related psychological disorder requiring therapy)
The tissue to be removed is glandular, not fatty tissue, verified by required histologic preoperative biopsy
Documentation of unilateral or bilateral grade II or larger breast enlargement (e.g., exceeding areola boundaries with edges that are indistinct from the chest)
Gynecomastia persists longer than 2 years
Adult males when ALL the following criteria are met:
Functional Impairment (e.g., chronic skin irritation, pain, related psychological disorder requiring therapy)
The tissue to be removed is glandular, not fatty tissue, verified by required histologic preoperative biopsy
No evidence of breast cancer
Documentation of unilateral or bilateral grade III or larger breast enlargement (e.g., exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present)
Medical causes ruled out with normal results of ALL the following:
Hormone evaluation (i.e., testosterone, luteinizing hormone, follicle-stimulating hormone, estradiol, prolactin, beta-human chorionic gonadotropin)
Liver enzymes
Serum Creatinine
Thyroid Function Test
Gynecomastia persists longer than 4 months following unsuccessful medical treatment
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g., statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
SOURCES
American Society of Plastic Surgeons. ASPS recommended insurance coverage criteria for third-party payers. Gynecomastia. Retrieved January 25, 2022 from https://www.plasticsurgery.org/Documents/Health-Policy/Positions/Gynecomastia_ICC.pdf.
BlueCross BlueShield Association. Evidence Positioning System. (3:2024). Surgical treatment of bilateral gynecomastia (7.01.13). Retrieved May 15, 2024 from www.bcbsaoca.com/eps/. (6 articles and/or guidelines reviewed)
Fricke, A., Lehner, G., Stark, G., & Penna. V. (2017). Long-term follow-up of recurrence and patient satisfaction after surgical treatment of gynecomastia. Aesthetic Plastic Surgery, 41 (3), 491-498. Abstract retrieved May 31, 2017 from PubMed database.
Mieritz, G.M., Christiansen, P., Jensen, M.B., Joensen, U.N., Nordkap, L., Olesen, I.A., et al. (2017). Gynaecomastia in 786 adult men: clinical and biochemical findings. European Journal of Endocrinology, 176 (5), 555-566. (Level 3 evidence)
Sollie, M. (2018). Management of gynecomastia-changes in psychological aspects after surgery- a systematic review. Gland Surgery, 7 (1), S70-S76. (Level 2 evidence)
ORIGINAL EFFECTIVE DATE: 1/1997
MOST RECENT REVIEW DATE: 6/13/2024
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.