Mastectomy for Gynecomastia*
Medical Policy: 07.01.15
Original Effective Date: March 1989
Reviewed: February 2012
Revised: April 2006
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy 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 will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Gynecomastia is the unilateral or bilateral enlargement of male breast tissue. Mastectomy for gynecomastia is a surgical procedure performed to remove breast glandular tissue from a male with enlarged breasts. Medications, physiologic states, and medical conditions can alter the balance of androgen and estrogen causing male breast growth. Before considering a type of medical treatment, it is important to keep in mind that gynecomastia has a high rate of spontaneous regression.
Approximately 40-65% of boys develop some degree of gynecomastia during puberty, which usually resolves spontaneously within two years, and rarely requires treatment. Enlargement sufficient to cause embarrassment and social disability occurs in fewer than 10% of those affected by puberty related gynecomastia.
While it is not necessary to evaluate every case of gynecomastia, the presence of an underlying tumor needs to be excluded and treated.
Procedures completed for cosmetic reasons (e.g. embarrassment or social disability) are not payable under the medical contract.
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Prior Approval:
Prior approval is recommended. Submit a prior approval now. 
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Policy:
Mastectomy for gynecomastia (either pubertal/adolescent-onset gynecomastia that has persisted for a least three years or post pubertal-onset that has persisted for one year) may be considered medically necessary when all of the following conditions have been met:
- Glandular breast tissue confirming true gynecomastia is documented on physical exam and/or mammography.
- The gynecomastia is classified as Grade II, III or IV per the American Society of Plastic Surgeons Classification, (See below)
- The condition is associated with documented persistent breast pain, despite the use of analgesics.
- The gynecomastia persists, despite correction or treatment of underlying causes including:
- Hormonal causes
- Potential gynecomastia-inducing drugs and substances
- Photographs have been submitted confirming the presence of the gynecomastia.
Mastectomy for gynecomastia is considered medically necessary if the member has documented enlargement with questionable malignancy, or the presence of nipple discharge. Usually present as a unilateral eccentric mass, hard or firm, that is fixed to the underlying tissues.
Mastectomy for gynecomastia is considered not medically necessary under any of the following circumstances:
- If the criteria listed above are not met
- If the surgery is performed for psychological reasons
- Breast enlargement resulting from obesity, or
- Breast enlargement resulting from medications
The American Society of Plastic Surgeons (ASPS) recommends using a scale adapted from the McKinney and Simon, Hoffman and Khan scales to characterize the severity of gynecomastia:
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Grade I
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Unilateral breast nodular enlargement, minor but visible breast enlargement without skin redundancy.
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Grade II
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Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. |
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Grade III
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Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present.
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Grade IV
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Marked breast enlargement with skin redundancy and feminization of the breast.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- CPT 19300 mastectomy for gynecomastia.
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Selected References:
- Bowers SP, et al. Cost effective management of gynecomastia. American Journal of Surgery 1998; 176 (6): 638-641.
- Bullmann C, Jockenhovel F. Gynecomastia in men. Fortschritte Der Medizin 1998; 116 (35-36): 18-22.
- Sher ES, Migeon CJ, Berkovitz GD. Evaluation of boys with marked breast development at puberty. Clinical pediatrics (Philadelphia) 1998; 37 (6): 367-371.
- The American Society of Plastic and Reconstructive Surgeons, Clinical Practice Guidelines: Plastic and Maxillofacial Surgery. Gynecomastia.1996: 1-6.
- Colombo-Benkmann M, Buse B, Stern J, Herfarth C. Indications for and results of surgical therapy for male gynecomastia. Am J Surg. 1999 Jul;178(1):60-3.
- Weiss JR, Moysich KB, Swede H. Epidemiology of male breast cancer. Cancer Epidemiol Biomarkers Prev. 2005 Jan;14(1):20-6. Abstract retrieved March 23, 2005 from PubMed database.
- Henley DV, Lipson N, Korach KS, Bloch CA. Prepubertal gynecomastia linked to lavender and tea tree oils. N Engl J Med. 2007;356(5):479-485.
- Braunstein GD. Gynecomastia. N Engl J Med 1993:328(7):490-495.
- eMedicine.com – Gawzi, A. Gynecomastia. January 25, 2005. eMedicine Specialties. (2005 September 13) <http://www.emedicine.com>.
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Policy History:
Date Reason Action
March 2011 Annual review Policy renewed
February 2012 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
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and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.
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