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| Mastectomy, Male Gynecomastia | |
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| Description: |
The policy applies to the following service/procedure: Mastectomy, Male Gynecomastia
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Policy/ Coverage: |
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
Mastectomy for gynecomastia
meets member benefit certificate Primary Coverage Criteria that there be scientific evidence of effectiveness in improving health outcomes or for members with contracts without Primary Coverage Criteria, is considered Medically Necessary and is covered when the following criteria are met:
Member receives a “recommended” determination from InterQual criteria review for mastectomy for gynecomastia
based on diagnosis and requested product. Click the following link to view the InterQual® criteria:
https://prod.ds.interqual.com/service/connect/transparency?tid=27b0a724-ca06-4b22-846b-598b8dae52fc
Does Not Meet Primary Coverage Criteria Or Is Not Covered For Contracts Without Primary Coverage Criteria
Mastectomy for gynecomastia does not meet member benefit certificate
Primary Coverage Criteria that there be scientific evidence of effectiveness in improving health outcomes and is not covered for any indication or circumstance not described above.
For contracts without Primary Coverage Criteria,
mastectomy for gynecomastia is considered not Medically Necessary
and is not covered or is investigational for any indication or circumstance not described above.
Not Medically Necessary or Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Effective May 01, 2021 - March 25, 2026
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
Mastectomy for gynecomastia in a male over age 18 meets member benefit certificate Primary Coverage Criteria that there be scientific evidence of effectiveness in improving health outcomes or for members with contracts without Primary Coverage Criteria is considered Medically Necessary and is covered if the tissue removed is glandular breast tissue and not the result of obesity, adolescence, or reversible effects of drug treatment that can be discontinued.
Does Not Meet Primary Coverage Criteria Or Is Not Covered For Contracts Without Primary Coverage Criteria
Mastectomy for gynecomastia in a male for any indication not described above does not meet member benefit certificate Primary Coverage Criteria that there be scientific evidence of effectiveness in improving health outcomes.
For members with contracts without Primary Coverage Criteria, mastectomy for gynecomastia in a male for any indication not described above is considered Not Medically Necessary or is investigational and is not covered. Not Medically Necessary or investigational services are specific contract exclusions in most member benefit certificates of coverage.
The removal of fatty tissue is considered cosmetic. Cosmetic services are considered a contract exclusion in most member benefit certificates.
Effective Prior To May 2021
Mastectomy for gynecomastia in a male over age 18 meets primary coverage criteria for effectiveness and is covered if the tissue removed is glandular breast tissue and not the result of obesity, adolescence, or reversible effects of drug treatment that can be discontinued. Removal of fatty tissue is considered cosmetic. Cosmetic services are an exclusion in the member benefit contract.
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| Rationale: |
A search of the MEDLINE database through August 2009 did not reveal any published literature that would prompt a change in the coverage statement.
2012 Update
A search of the MEDLINE database through May 15th did not reveal any new literature that would prompt a change in the coverage statement.
2015 Update
A literature search conducted using the MEDLINE database through April 2015 did not reveal any new information that would prompt a change in the coverage statement.
2016 Update
A literature search conducted through March 2016 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
A systematic review published in 2015 included 14 studies on the treatment of gynecomastia (Fagerlund, 2015). None of the studies were randomized, all were judged to be at high risk of bias, and the body of evidence was determined to be of very low quality by GRADE evaluation.
Summary of Evidence
The evidence for surgical treatment of bilateral gynecomastia in males includes case series. Relevant outcomes are functional status, health status measurements and treatment-related morbidity. There are no randomized controlled trials on surgical treatment of bilateral gynecomastia, therefore it is not possible to determine whether surgical treatment improves functional impairment. Conservative therapy should adequately address any physical pain or discomfort and gynecomastia does not typically cause functional impairment. The evidence is insufficient to determine the effect of the technology on health outcomes.
2017 Update
A literature search conducted using the MEDLINE database through April 2017 did not reveal any new information that would prompt a change in the coverage statement.
2018 Update
Annual policy review completed with a literature search using the MEDLINE database through April 2018. No new literature was identified that would prompt a change in the coverage statement.
2019 Update
A literature search was conducted through April 2019. There was no new information identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
Nonrandomized Studies
Exposure of new techniques, quality of life assessments and other nonsurgical outcomes have been reported in the literature.
Abdelrahman published a retrospective analysis of 18 patients with grade I-II gynecomastia treated with a combination of traditional liposuction and glandular liposculpturing between 2014 and 2016 (Abdelrahman, 2018). Outcomes assessed included treatment-related morbidity and adverse events and patient reported outcomes (PROs). The PROs included patient satisfaction using the Breast Evaluation Questionaire (BEQ). Other notable information gained includes treatment-related morbidity and adverse events. The post-operative aesthetic appearance was evaluated by 5 independent plastic surgeons (“observers”) who were blinded to the surgery performed making their assessments based on preoperative and 6 month postoperative photographs. The observers concluded that an acceptable post-operative result was achieved (92% of the ratings); 8% of the ratings suggested subsequent liposuction needed to be performed. The level of agreement was assessed and statistically significant for varying aesthetic variables (eg, nipple projection, p=.005). Treatment-related morbidities or adverse events were minimal and include wound infection (1/18, 5.56%) and complaints of breast-tissue remnants and requests for subsequent operation (2/18, 11.1%).
Nuzzi et al published a longitudinal cohort study aimed at measuring changes in health-related quality of life following surgical management of gynecomastia in adolescents using 3 surveys administered over a 5-year period to both the intervention group and age- and sex-matched controls (Nuzzi, 2018). The surveys administered were the Short-form 36v2 (SF-36), Rosenberg Self-Esteem Scale (RSES), and Eating-Attitudes Test-26. From 2008 to 2017, 44 patients who underwent treatment of gynecomastia and 64 unaffected controls who participated in the study. Patients in the intervention group scored significantly poorer at baseline compared with controls on both the RSES and EAT-26 (p<.05, both), even after controlling for BMI differences. Gynecomastia patients scored lower on five SF-36 domains than the controls: general health, vitality, social functioning, role-emotional, and mental health (p<.05, all). Scores significantly improved post-operatively on the RSES and in four SF-36 domains. Post-operatively, gynecomastia patients scored similarly to the control group on the SF-36 and RSES, indicating an improvement in quality of life.
2020 Update
A literature search was conducted through April 2020. There was no new information identified that would prompt a change in the coverage statement.
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through April 2021. No new literature was identified that would prompt a change in the coverage statement.
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through April 2022. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
In 2019, the American Society of Andrology, in collaboration with the European Academy of Andrology, released clinical practice guidelines on gynecomastia evaluation and management (Kanakis, 2019). Their recommendation related to surgical intervention is as follows:
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through April 2023. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
A systematic review by Prasetyono et al included 18 studies (N=244) on liposuction-assisted gynecomastia surgery in patients with specified Simon’s classification of gynecomastia grade I and II (Prasetyono, 2022). The method of patient satisfaction rating also varied between studies which resulted in difficulties interpreting the results. Only 2 studies were considered good quality in terms of level of evidence, and the authors noted that there was a high risk of bias in all included studies which precludes them from drawing any non-biased conclusion.
Liu et al reported on a cohort of 34 patients (N=50 breasts; 16 bilateral and 18 unilateral) diagnosed with glandular gynecomastia who were treated with endoscope-assisted minimally invasive surgery (Liu, 2022). According to Simon's classification of gynecomastia, grade I (n=10), grade IIA (n=25), and grade IIB (n=15) patients were included. Race or ethnicity of patients were not described. Median follow-up duration was 21 months (range, 12 to 34). Short-term complications included pain, postoperative bleeding, and subcutaneous seroma. Long-term complications included dysesthesia of the nipple-areolar complex and redundant skin. Cosmetic outcomes were assessed by 2 surgeons at 6 months post-procedure. Cosmetic outcomes based on predetermined criteria were as follows: very good (15/34; 44.1%), good (17/34; 50%), and average (2/34; 5.9%). Satisfaction of patients was scored using a 5-point Likert scale, and the average was 4.4 points (+/- standard deviation of 0.5).
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2024. No new literature was identified that would prompt a change in the coverage statement.
2025 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2025. No new literature was identified that would prompt a change in the coverage statement.
2026 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2026. No new literature was identified that would prompt a change in the coverage statement.
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| Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants. | |
| CPT Codes Copyright © 2026 American Medical Association. | |