BlueCross and BlueShield of Montana Medical Policy/Codes
Surgical Treatment of Bilateral Gynecomastia
Chapter: Surgery: Procedures
Current Effective Date: October 25, 2013
Original Effective Date: December 18, 2009
Publish Date: October 25, 2013
Revised Dates: February 15, 2012; September 24, 2013
Description

Gynecomastia refers to the benign enlargement, unilateral or bilateral, of the male breast due to an increase of:

  • Adipose (fat) tissue,
  • Glandular tissue,
  • Fibrous tissue, or
  • A combination of all three.

Gynecomastia is the most common breast lesion in males, accounting for more than 65% of breast disorders in men.

Gynecomastia may be associated with any of the following:

  • An underlying hormonal disorder, for example, conditions causing an imbalance of estrogen or testosterone found in liver disease, kidney failure, genetic disorders, an endocrine disorder, or tumors;
  • A side effect of certain drugs (prescription, over the counter, or illegal);
  • Cancer treatments (chemotherapy or hormonal/androgen therapies or blockades);
  • Steroid abuse;
  • Obesity; or
  • Specific age groups, such as:
    1. Newborns or neonates, due to action of maternal or placental estrogens;
    2. Adolescent or pubertal, which consists of transient or short term, regressing in two to three years and bilateral breast enlargement that can be tender; or
    3. Adult aging, related to the decreasing levels of testosterone and relative estrogen increases.

Some adolescents and adults have fatty tissue on their chests that gives the appearance of gynecomastia.  This condition is called pseudogynecomastia or false gynecomastia.  In some patients, symptoms of true mastitis can occur.  The possibility of cancer must be considered with breast enlargement in the adult male, accounting for approximately 1% of all breast cancers in the United States.  True pubertal gynecomastia is common, 38% in males 10 to 16 years of age, increasing or peaking to 65% at age 14 years, then decreasing at age 16 years.  Generally, pubertal gynecomastia regresses within six months, 75% within two years, and 90% within three years. 

The indications for treatment are dependent on the prolonged presence of breast enlargement in the male patient.  The hypertrophy of the breast tissue usually causes the patient to have a somewhat feminine appearance.  The enlarged breasts will often give distention and tightness to the breast, which can cause pain and discomfort.  Treatment for underlying hormonal disorders may require cessation of drug therapy or weight loss.  Adolescent gynecomastia may resolve with aging.

The Gynecomastia Scale, adapted from the McKinney and Simon, Hoffman and Kohn scales used in the 1970’s to assess levels of male breast enlargement, is recommended by the American Society of Plastic Surgeons to grade breast growth and is as follows:

Grade I:          Unilateral breast nodular enlargement, minor but visible breast enlargement without skin redundancy.

Grade II:         Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest, with or without skin redundancy.

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.

Mastectomy for gynecomastia is a surgical procedure to remove breast glandular tissue from a male with enlarged breasts, similar to subcutaneous mastectomy procedure performed on a female patient.  Liposuction-assisted mastectomy has become a popular method used for pseudogynecomastia.  An ultrasound modality may or may not accompany the liposuction technique.

Policy

Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.  Members and their providers have the responsibility for consulting the member's benefit plan or contract to determine if there is any exclusion or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern.

Coverage

Mastectomy for gynecomastia by any method (including subcutaneous and/or suction lipectomy, liposuction, or lipoplasty assisted gynecomastia mastectomy) is considered cosmetic because gynecomastia does not result in functional impairment.  This determination applies regardless of the underlying condition including, but not limited to, an underlying hormonal disorder, obesity, adolescence and other age related breast tissue enlargement symptoms, and/or the reversible side effects of drug treatment.

Mastectomy and reduction mammaplasty, including mastopexy, in male patients are considered to be done primarily to alter physical appearance. They are therefore considered cosmetic procedures.

Special Comment regarding Cosmetic Services:  Determination of benefit coverage for procedures considered to be cosmetic is based on how a member's benefit contract defines cosmetic services and their eligibility for benefit coverage.

NOTE:  This policy does not address the use of mastectomy for a male patient to remove breast tissue following a biopsy confirming a malignancy.

Rationale

Gynecomastia is a benign enlargement of the male breast commonly occurring in healthy adolescent boys and in adults (50 to 80 years old).  It may be a source of cosmetic and psychologic problems.  The pain associated with adolescent gynecomastia is typically self-limiting or responds to analgesic therapy.  The secondary forms usually require no therapy other than the removal of any identified inciting cause.  Most of the idiopathic forms last only a few months and gradually disappear.  In the secondary gynecomastia and idiopathic forms that present for longer than 12 months and when hormonal treatment fails, a mastectomy may be the next form of therapy.

If the breast enlargement is due to a tumor, then the tumor must be treated.   Breast cancer is rare in males.  If there is any question of cancer, a mammogram and biopsy will be performed prior to a mastectomy.           

Concepts of medical necessity are based on the presence of a functional impairment.  Typically no functional impairment is associated with gynecomastia; therefore treatment of gynecomastia is considered cosmetic and directly related to cosmetic and reconstructive service contract benefits or exclusions.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

Refer to the ICD-9-CM manual.

ICD-10 Codes
N62, 0HBT0ZZ, 0HBT3ZZ, 0HBU0ZZ, 0HBU3ZZ, 0HBV0ZZ, 0HBV3ZZ 
Procedural Codes: 15839, 19300
References
  1. Berkow, Robert and Andrew J. Fletcher, eds.  The Merck Manual - 17th edition.  New Jersey: Merck & C., Inc. (1992) 815.
  2. Gynecomastia: Recommended Criteria for Third-Party Payer Coverage – Position paper. Arlington Heights, Illinois: American Society of Plastic and Reconstructive Surgeons, Inc. (1992 March).
  3. Gynecomastia: Recommended Criteria for Third-Party Payer Coverage – Position paper. Arlington Heights, Illinois: American Society of Plastic and Reconstructive Surgeons, Inc. (1995 October).
  4. Mastectomy for Gynecomastia. Chicago, Illinois: Blue Cross Blue Shield Association Consortium Health Plan Medical Policy Reference Manual (1995 December 1) Surgery: 7.01.13.
  5. Cianchetti, E., Legnini, M., et al.  Gynecomastia. Annali Italiani Di hirugia (1996 July-August) 67(4): 495-9, 499-500.  
  6. Bradshaw, K.D.  Contrasexual Disorders and Delayed Puberty. Hospital Medicine (1997) 33(10): 51-4, 57.
  7. AAFP.org – Gynecomastia: When Breasts Form in Males – Patient Information Handout. July 13, 1998. American Academy of Family Physicians (1999 January 25) http://www.aafp.org .
  8. Colombo-Benkmann, M., Buse, B., et al.  Indications for and results of surgical therapy for male gynecomastia.  American Journal of Surgery (1999 July) 178(1): 60-3.
  9. Evans, G.F., Anthony, T., et al.  The diagnostic accuracy of mammography in the evaluation of male breast disease.  American Journal of Surgery (2001 February) 181(2): 96-100.
  10. Pershichetti, P., Berloco, M., et al.  Gynecomastia and the complete circumareolar approach in the surgical management of skin redundancy.  Plastic and Reconstructive Surgery (2001 April 1) 107(4): 948-54.
  11. Gruntmanis, U. and G.D. Braunstein.  Treatment of gynecomastia.  Current Opinion in Investigational Drugs (2001 May) 2(5): 643-9.
  12. Goes, J.C. and A. Landecker.  Ultrasound-assisted lipoplasty (UAL) in breast surgery.  Aesthetic Plastic Surgery (2002 January-February) 26(1): 1-9.
  13. Lazala, C. and P. Saenger.  Pubertal gynecomastia.  Journal of Pediatric Endocrinology and Metabolism (2002 May) 15(5): 553-60.
  14. Meguerditchian, A.N., Flardeau, M., et al.  Male breast carcinoma.  Canadian Journal of Surgery (2002 August) 45(4): 296-302.
  15. Boljanovic, S., Axelsson, C.K., et al.  Surgical treatment of gynecomastia: Liposuction combined with subcutaneous mastectomy.  Scandinavian Journal of Surgery (2003) 92(2): 160-2.
  16. Surgical Treatment of Bilateral Gynecomastia.  Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2003 July) Surgery: 7.01.13.
  17. Rohrich, R.J., Ha, R.Y., et al.  Classification and management of gynecomastia: Defining the role of ultrasound assisted liposuction.  Plastic and Reconstructive Surgery (2003 February) 111(2): 909-25.
  18. eMedicine.com – Gawzi, A. Gynecomastia.  January 25, 2005. eMedicine Specialties. (2005 September 13) http://www.emedicine.com.
  19. eMedicine.com – Roubidoux, M.A., Breast Cancer, Male.  February 2, 2005. eMedicine Specialties. (2005 September 13) http://www.emedicine.com .
History
February 2012 Policy updated with literature search. Liposuction added to the policy statement. Reference 3 added.
October 2013 Policy formatting and language revised.  Title changed from "Surgical Treatment of Bilateral Gynecomastia" to "Mastectomy for Gynecomastia".  Policy statement changed from not medically necessary to cosmetic.  Added CPT code 15839 and removed 19140 and 19120.
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Surgical Treatment of Bilateral Gynecomastia