Bilateral gynecomastia refers to the benign enlargement of the male breast, either due to increased adipose tissue, glandular tissue, fibrous tissue, or a combination of all three. 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)
• A side effect of certain drugs
• Associated with obesity
• Related to specific age groups, i.e.,
• Neonatal gynecomastia, related to action of maternal or placental estrogens
• Adolescent gynecomastia, which consists of transient, bilateral breast enlargement, which may be tender
• 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. Adolescent gynecomastia may resolve with aging. Surgical removal of the breast tissue, using either surgical excision or liposuction may be considered if the above conservative therapies are not effective or possible.

Mastectomy as a treatment of gynecomastia is considered not medically necessary due to the lack of a functional impairment. See Benefit Applications below, for discussion of potential coverage eligibility based on reconstructive services.

BlueCard/National Account Issues

Concepts of medical necessity are based on the presence of a functional impairment. Typically no functional impairment is associated with gynecomastia. Therefore, determination of coverage eligibility for the surgical treatment of bilateral gynecomastia may require consideration of whether or not such surgery would be considered either essentially cosmetic in nature or reconstructive. (See policy No. 10.01.09 for further discussion of functional impairment, and general concepts of reconstructive and cosmetic services.) Contractual definitions of the scope of reconstructive services that may be eligible for coverage vary. Categories of conditions that may be included as part of the contractual definition of reconstructive services include some or all of the following:

• Post-surgery
• Accidental trauma or injury
• Diseases
• Congenital anomalies
• Anatomic variants
• Post-chemotherapy

For example, adolescent gynecomastia may be considered an anatomic variant, while gynecomastia related to liver disease would be considered secondary to a disease process.

As noted above, coverage eligibility for treatment of bilateral gynecomastia is largely a contract/benefits issue, related to the distinction between cosmetic and reconstructive services. The surgical procedure may involve surgical excision (i.e., mastectomy) or 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.

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):909-25.
2. Goes JC, Landecker A. Ultrasound-assisted lipoplasty (UAL) in breast surgery. Aesthetic Plast Surg 2002; 26(1):1-9

Gynecomastia, mastectomy for
Mastectomy for gynecomastia