Mastectomy for gynecomastia is a surgical procedure performed to remove glandular breast tissue from a male with enlarged breasts. This policy addresses mastectomy for gynecomastia. 

Note:  For information related to medical necessity criteria for reduction mammaplasty and other reconstructive breast procedures, refer to SURG.00086 Reduction Mammaplasty and SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures.

Medically Necessary:

Mastectomy (including reconstruction if necessary) for gynecomastia in patients over the age of 18, or 18 months after the end of puberty, whichever is younger, is considered medically necessary when the following criteria are met:

1. The tissue removed is glandular breast tissue and not the result of obesity, adolescence, or reversible effects of a drug treatment which can be discontinued (this would include drug-induced gynecomastia remaining unresolved six months after cessation of the causative drug therapy); AND
2. Appropriate diagnostic evaluation has been done for possible underlying etiology; AND
3. Patient has pain or tenderness directly related to the breast tissue and is documented in the medical record which has a clinically significant impact upon activities of daily living and has been refractory to a trial of analgesics or anti-inflammatory agents (for a reasonable time period adequate to assess therapeutic effects); AND
4. Pre-operative photographs are provided.

Conditions that may be associated with gynecomastia include, but are not limited to:

1. Documented androgen deficiency;
2. Chronic liver disease that causes decreased androgen availability;
3. Klinefelter’s syndrome (47XYY);
4. Adrenal tumors that cause androgen deficiency or increased secretion of estrogen;
5. Brain tumors that cause androgen deficiency;
6. Testicular tumors causing androgen deficiency or tumor secretion of estrogen;
7. Endocrine disorders e.g., hyperthyroidism.

Mastectomy for gynecomastia is considered medically necessary, regardless of patient age , when there is legitimate concern that a breast mass may represent breast carcinoma.  Mammography may be of value to determine the need for surgery in some instances.

Reconstructive:

Mastectomy (including reconstruction if necessary) for gynecomastia in patients over the age of 18, or 18 months after the end of puberty, whichever is younger, is considered reconstructive if it does not meet the medical necessary criteria above and is for drug induced gynecomastia that does not resolve by 6 months after the cessation of drug therapy. Some agents associated with the occurrence of gynecomastia are listed in the Rationale section of this policy. This list is not all inclusive.

Not Medically Necessary:

Mastectomy for gynecomastia is considered not medically necessary when the above criteria are not met.

Investigational/Not Medically Necessary:

The use of liposuction to perform mastectomy for gynecomastia is considered investigational/not medically necessary .

Gynecomastia has been linked to several disorders affecting the endocrine system, as well as being a side effect from certain drugs. Frequently, treating the underlying condition, such as removal of a tumor or changing medications, will resolve gynecomastia. Such conservative measures should be attempted prior to any surgical approach to gynecomastia. Some drugs associated with the occurrence of gynecomastia include, but are not limited to:

• Estrogens;
• Androgens;
• Spironolactone;
• Digitalis preparations;
• Flutamide;
• Ketoconazole;
• Cimetidine.

Drugs of abuse that can also be associated with the development of gynecomastia include: steroids, alcohol, and marijuana. The medical literature indicates that gynecomastia is due to the stimulated growth of glandular breast tissue and does not significantly affect the disposition of fatty tissue. Therefore, mastectomy for gynecomastia must focus on the removal of glandular tissue underlying the condition. The use of liposuction as a method of mastectomy for gynecomastia has not been proven to remove glandular tissue and is not considered an acceptable alternative to standard surgical approaches.

Gynecomastia, being a proliferative condition of the male breast, can occasionally lead to concern about the development of carcinomatous changes in the breast. In some cases, biopsy results do not lead to a clear distinction between non-cancerous and cancerous breast tissue. In such cases, mastectomy is indicated regardless of patient age to properly address those concerns.

True gynecomastia is a result of a variety of conditions causing a hormonal imbalance and results in the growth of glandular breast tissue in males. This condition should not be confused with pseudo-gynecomastia, which is an enlargement of the breast due to fat deposition. According to the American Society of Plastic Surgeons, gynecomastia is usually a transient phenomenon in up to 60 to 70 percent of pubescent boys and is considered a normal part of male adolescence. The peak incidence occurs at 14 to 14 1/2 years, and spontaneously resolves in one to two years after onset. For this reason, clinical observation for a 12-24 month period of time is sometimes employed by treating physicians. However, about 30 to 40 percent of adult men have been found to have gynecomastia.  Frequently, the cause is unknown and not due to tumors of the endocrine system or drug-induced side effects. True gynecomastia, which has an unknown cause, is usually long-standing.  Medical and laboratory investigation is frequently unnecessary to determine a cause. In such cases, surgery is the only treatment alternative.  Gynecomastia that is unilateral in post-adolescent age groups or that has a rapid onset is frequently associated with an underlying pathology. For this reason, careful clinical evaluation is warranted to rule out possible pathological etiologies, prior to any surgical interventions. In such cases, when doctors are able to determine the cause of the gynecomastia and address it appropriately, spontaneous resolution of the gynecomastia usually occurs over a short period of time.

Gynecomastia: excessive development of the male mammary glands, due mainly to ductal proliferation with periductal edema; mild gynecomastia may occur in normal adolescence.

Mastectomy: surgical removal of a breast.

The following codes for treatments and procedures applicable to this policy are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Medically Necessary:

CPT

ICD-9 Procedure

ICD-9 Diagnosis

Services may be Medically Necessary or Reconstructive when criteria are met:

For the procedure codes listed above for all other diagnoses when medically necessary or reconstructive criteria are met

When services are Not Medically Necessary:

For the procedure codes listed above, when policy criteria are not met; or when the code describes a procedure indicated in the Policy section as not medically necessary.

When services are Investigational/Not Medically Necessary:

CPT

ICD-9 Diagnosis

Peer Reviewed Publications:

1. Arca MJ, Caniano DA. Breast disorders in the adolescent patient. Adolesc Med Clin. 2004; 15(3):473-85.
2. Colombo-Benkmann M, Buse B, Stern J, Herfarth C. Indications for and results of surgical therapy for male gynecomastia. Am J Surg. 1999; 178(1):60-3.
3. Hammond DC, Arnold JF, Simon AM, Capraro PA. Combined use of ultrasonic liposuction with the pull-through technique for the treatment of gynecomastia. Plast Reconstr Surg. 2003; 112(3):891-5.
4. Matarasso SL. Liposuction of the chest and back. Dermatol Clin. 1999; 17(4):799-804. 
5. McGrath MH, Schooler WG. Elective plastic surgical procedures in adolescence. Adolesc Med Clin. 2004; 15(3):487-502. 

Government Agency, Medical Society, and Other Authoritative Publications:

1. Behrman RE, et al. Nelson’s Textbook of Pediatrics, 15th Edition. W. B. Saunders Company, Philadelphia.1996:1634.
2. Hathaway WE, et al. Current Pediatric Diagnosis and Treatment. Appleton & Lange, Norwalk. 1994:312-313.
3. Stein’s Internal Medicine, 5th Edition.1998 Part Nine – Endocrinology, Metabolism, and Genetics; III Clinical Syndromes, Chapter 293 Gynecomastia, John C. Marshall. STAT! Ref Medical Reference Fourth Qtr. ’02. Copyright© 1994 Mosby-Year Book, Inc. 
4. Townsend. Sabiston Textbook of Surgery, 16th edition. W. B. Saunders Company, 2001:559, 1567.
5. Way LE, et al. Current Surgical Diagnosis and Treatment, 10th Edition. Appleton & Lange, Norwalk.1994:312-313. 
6. Williams Textbook of Endocrinology, 9th Edition.Copyright 1998, W. B. Saunders Company; Disorders of Breasts in Men Gynecomastia.

1. National Cancer Institute: What you need to know about breast cancer. Available at:       http://www.cancer.gov/cancer_information/doc_wyntk.aspx? viewid=41a364e8-6f7e-4c6c-981a-fce1c07f9c5d. Accessed on April 28, 2006.

Gynecomastia
Mastectomy for Gynecomastia

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.

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