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MP 7.01.13 Surgical Treatment of Bilateral Gynecomastia

Medical Policy    
Section
Surgery 
Original Policy Date
12/1/95
Last Review Status/Date
Reviewed with literature search/10:2013
Issue
10:2013
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Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

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. Surgical removal of the breast tissue, using either surgical excision or liposuction may be considered if conservative therapies are not effective or possible.

Background

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
  • 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. Gynecomastia may also resolve spontaneously and adolescent gynecomastia may resolve with aging.

Prolonged gynecomastia causes periductal fibrosis and stromal hyalinization, which prevents regression of the breast tissue. 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 and the gynecomastia does not resolve spontaneously or with aging.


Policy

Surgical removal of breast tissue, such as mastectomy or liposuction, 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.


Benefit Application
BlueCard/National Account Issues

One of the bases for medical necessity is the presence of a functional impairment. For treatment of bilateral gynecomastia, the presence of functional impairment is a primary consideration. 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, which may be included as part of the contractual definition of reconstructive services, include some or all of the following:

  • Postsurgery
  • Accidental trauma or injury
  • Diseases
  • Congenital anomalies
  • Anatomic variants
  • Postchemotherapy

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

Determinations of whether a proposed therapy would be considered reconstructive or cosmetic should always be interpreted in the context of the specific benefits language. State or federal mandates may also dictate coverage decisions.


 Rationale

This policy was originally created in 1995 and was updated with searches of the MEDLINE database. The most recent literature search was performed for the period of September 2012 through August 2013. The following is a summary of the key findings to date.

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.

In order 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 on literature search.

Ongoing Clinical Trials

No clinical trials were identified that addressed surgery for gynecomastia in a search of online site ClinicalTrials.gov on September 9, 2013.

Summary

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. Surgical removal of the breast tissue, using either surgical excision or liposuction may be considered if conservative therapies are not effective or possible.

There are no randomized controlled trials on surgical treatment of bilateral gynecomastia that address functional impairment. Since conservative therapy should adequately address any physical pain or discomfort and gynecomastia does not typically cause functional impairment, surgical treatment of bilateral gynecomastia is considered not medically necessary.

Practice Guidelines and Position Statements

The American Society of Plastic Surgeons (ASPS) issued practice criteria for third-party payers. (3) In this document, the ASPS classified gynecomastia with 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 grade III gynecomastia may be appropriate if the gynecomastia persists for more than 1 year after pathological 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 grade IV gynecomastia may be appropriate if the gynecomastia persists for more than 3-4 months after pathological causation is ruled out and continues after 3-4 months of medical treatment that is unsuccessful. The ASPS also indicates surgical treatment of gynecomastia may be appropriate when distention and tightness cause pain and discomfort.

Medicare National Coverage

No national coverage determination.

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.
  2. Goes JC, Landecker A. Ultrasound-assisted lipoplasty (UAL) in breast surgery. Aesthetic Plast Surg 2002; 26(1):1-9.
  3. American Society of Plastic Surgeons. ASPS Recommended Insurance Coverage Criteria for Third-Party Payers. 2002. Available online at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/insurance/Gynecomastia-Insurance-Coverage.pdf. Last accessed September 2013

Codes

Number

Description

CPT  19300 Mastectomy for gynecomastia 
ICD-9 Procedure  85.31  Unilateral reduction mammoplasty 
  85.32  Bilateral reduction mammoplasty (for gynecomastia) 
ICD-9 Diagnosis  611.1  Hypertrophy of breast (includes gynecomastia) 
HCPCS  No code 
ICD-10-CM (effective 10/1/14)     Not medically necessary for all relevant diagnoses 
  N62                                                      Hypertrophy of breast (includes gynecomastia) 
ICD-10-PCS (effective 10/1/14)                                                                ICD-10-PCS codes are only used for inpatient services.
 

0HBT0ZZ, 0HBT3ZZ, 0HBU0ZZ,

0HBU3ZZ, 0HBV0ZZ, 0HBV3ZZ 

Surgical, excision, breast, code by body part (right, left or bilateral) and approach (open or percutaneous) 
Type of Service  Surgery 
Place of Service  Inpatient 


Index

Gynecomastia, mastectomy for
Mastectomy for gynecomastia


Policy History

Date Action Reason
12/01/95 Add to Surgery section New policy
4/15/02 Replace policy Policy reviewed without literature review; new review date only
10/9/03 Replace policy Policy revised; coverage eligibility treatment of gynecomastia no longer considered medically necessary; reframed as either a cosmetic or reconstructive service when a functional impairment is not present
11/10/11 Replace policy Policy updated with literature search. Liposuction added to the policy statement which remains not medically necessary. Reference 3 added.
11/8/12 Replace Policy Policy updated with literature review; policy statement unchanged
10/10/13 Replace policy Policy updated with literature review through August 2013; no new references added, policy statement unchanged