mp-114 - Medical Policies - Alabama
Policy Number: MP-114
Latest Review Date: February 2022
Effective for dates of service after April 9, 2021:
Mastectomy for gynecomastia may be considered medically necessary for adult patients (≥ 18 years of age) with symptoms that have persisted for one year OR adolescent patients (≤18 years of age) with symptoms that have persisted for at least two years when ALL of the following criteria are met:
- Glandular breast tissue confirming true gynecomastia is documented on physical examination and/or mammography (medical records must contain frontal and lateral view preoperative photographs); AND
- Gynecomastia is classified as Grade II, III or IV per the American Society of Plastic Surgeons classification; AND
- Gynecomastia is associated with persistent breast discomfort despite the use of analgesics; AND
- Presence of an underlying pathologic process (e.g. breast, adrenal or testicular tumors, kidney or liver disease) has been ruled out; AND
- Use of potential gynecomastia-inducing drugs and substances has been identified and discontinued for at least one year, when medically appropriate; AND
- Hormonal causes have been excluded by appropriate laboratory testing and, if present, have been treated for at least one year prior to surgery. These include but are not limited to the following as confirmed by laboratory testing:
- Hyperthyroidism (e.g., thyroid stimulating hormone [TSH])
- Excess estrogen (e.g., excess estradiol)
- Prolactinomas (e.g., prolactin)
- Hypogonadism (e.g., testosterone, human chorionic gonadotropin [hCG], and/or luteinizing hormone [LH])
Mastectomy for gynecomastia is considered not medically necessary in all other circumstances including but not limited to the following
- Pubertal gynecomastia with tender palpable breast tissue or fatty tissue;
- Gynecomastia surgery to improve the appearance of the breast or to alter the contours of the chest wall;
- Surgery to remove excess adipose (fat) tissue (pseudogynecomastia);
- Use of liposuction to perform gynecomastia surgery
Effective for dates of service prior to April 9, 2021:
Mastectomy for gynecomastia may be considered medically necessary for:
- Adult and mid to late pubertal (age 14 to 20) patients with non-tender, palpable breast tissue;
- Adult patients with recent onset of progressive breast enlargement with or without tenderness;
- Patients with Klinefelter’s Syndrome.
The following information will be used to determine if true gynecomastia is present (except in those patients with Klinefelter’s Syndrome). True gynecomastia is defined as the presence of glandular tissue and not fatty tissue:
- Full history that includes conditions present for at least 12 months on an adolescent, medication history to include drugs, alcohol, and specific questions regarding hepatic dysfunction, testicular insufficiency (decreased libido or impotence), pulmonary symptoms suggestive of lung cancer, and hyperthyroidism;
- Physical exam that includes description of palpation of breast, evidence of any alteration of expected secondary sexual characteristics, and testicular, liver, and thyroid examination;
- Work-up of any abnormal findings;
- Medical evaluation to exclude endocrinopathy;
- Pre-op photos;
- Post-operatively, a pathology report may be requested to confirm the presence of glandular tissue as removal of fatty tissue is considered cosmetic.
For an adult patient with recent onset of progressive breast enlargement, with or without tenderness and mid to late pubertal patients, the following additional information will be used to determine true gynecomastia versus other etiologies. True gynecomastia is defined as the presence of glandular tissue and not fatty tissue:
- Emphasis on drug-induced gynecomastia (with discontinuance of the drug, if possible, for one month with re-evaluation);
- Measurement of serum chorionic gonadotropin, testosterone, estradiol, and luteinizing hormone is required when no underlying cause is apparent;
- If reports result in diagnosis of idiopathic gynecomastia, the condition may be monitored for six months.
Mastectomy for gynecomastia is considered not medically necessary for:
- Pubertal gynecomastia with tender palpable breast tissue or fatty tissue;
- Drug related gynecomastia (these may include but not limited to: androgens and anabolic steroids, oral and topical estrogens, spironolactone, methyldopa, phenytoin, cimetidine, digitalis, psychoactive agents, alcohol, marijuana);
- Removal of fatty tissue.
The plan will not cover mastectomy for gynecomastia performed by liposuction ONLY.
DESCRIPTION OF PROCEDURE OR SERVICE
Gynecomastia is the benign enlargement of the male breast, either due to increased adipose tissue, glandular tissue, fibrous tissue, or a combination of all three. This condition should not be confused with pseudogynecomastia, which is an enlargement of the male breast due to excess fat deposition. Gynecomastia can be attributed to physiologic, pathologic, or pharmacologic causes. Physiologically in newborns breast development may be associated with galactorrhea. It is also seen with aging and teenage boys. Causes of pathologic gynecomastia may include testicular and pituitary tumors, chronic liver disease, genetic disorders/congenital endocrine conditions (Klinefelter’s disease) and kidney failure.
In adults, it has been suggested that approximately 45-50% of cases are associated with an underlying pathology. Adolescent gynecomastia is considered a normal variation of puberty that rarely persists and typically spontaneously regresses within 18 to 24 months. If adolescents have surgical therapy before completion or at near completion of their puberty, the hormonal imbalance that caused the gynecomastia may cause recurrence. Especially in children and youths, most cases of gynecomastia have no absolute indication for therapeutic intervention, as they are temporary and show a high number of spontaneous remissions.
The most common cause of gynecomastia in the male is puberty. It accounts for more than 65 percent of male breast disorders. The condition may occur in one or both breasts and begins as a small lump beneath the nipple, which may be tender. Gynecomastia during puberty is not uncommon, is self-limiting and usually resolves spontaneously within two years. The etiology appears to be related to an increase in estrogens, a decrease in androgens or some alteration in the estrogen-androgen level. Gynecomastia may also result as a side effect from certain drugs including, but not limited to: estrogens, androgens, spironolactone, digitalis preparations, flutamide, ketoconazole, cimetidine, anabolic steroids, alcohol, amphetamines, and marijuana.
Careful clinical evaluation is warranted to rule out possible pathological etiologies prior to any surgical intervention. When a cause of the gynecomastia is determined and addressed appropriately, spontaneous resolution of the gynecomastia usually occurs over a short period.
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. A variety of surgical techniques have been described as being used to perform mastectomy for gynecomastia, including direct excision, liposuction or a combination of both.
This has been updated regularly with searches of the MEDLINE database. The most recent literature update was performed through December 17, 2021.
Summary of Evidence
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 should focus on the removal of glandular tissue underlying the condition. The use of liposuction as a method of mastectomy for gynecomastia has not been sufficiently proven to remove glandular tissue and is not considered an acceptable alternative to standard surgical approaches.
Practice Guidelines and Position Statements
The American Society of Plastic Surgeons
The American Society of Plastic Surgeons (ASPS) issued practice criteria for third-party payers in 2002, which was reaffirmed in 2015. ASPS classified gynecomastia using the following scale, which was “adapted from the McKinney and Simon, Hoffman and Kohn scales”:
Small breast enlargement with localized button of tissue that is concentrated around the areola.
Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest.
Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present.
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 III gynecomastia may be appropriate if the gynecomastia persists for more than one year after pathological causation is ruled out (or six months if grade IV) and continues after six months if medical treatment is unsuccessful. In adults, surgical treatment for unilateral or bilateral grade III or grade IV gynecomastia is ruled out and continues after three to four months after pathological causation is ruled out and continues after three to four 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.
American Society of Andrology
In 2019, the American Society of Andrology, in collaboration with the European Academy of Andrology, released clinical practiceguidelines on gynecomastia evaluation and management.7, Their recommendation related to surgical intervention is as follows:
- "We suggest surgical treatment only for patients with long-lasting GM [gynecomastia], which does not regress spontaneously orfollowing medical therapy. The extent and type of surgery depend on the size of breast enlargement, and the amount of adiposetissue [weak recommendation, low quality of evidence]."
U.S. Preventive Services Task Force Recommendations
Surgery for gynecomastia is not a preventive service.
APPROVED BY GOVERNING BODIES
Removal of breast tissue is a surgical procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration.
Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.
ITS: Home Policy provisions apply
FEP contracts: FEP does not consider investigational if FDA approved and will be reviewed for medical necessity. Special benefit consideration may apply. Refer to member’s benefit plan.
Mastectomy for gynecomastia
- AAFP Core Educational Guidelines, American Family Physician, August 1999, Vol. 60, No. 2.
- Abdelrahman I, Steinvall I, Mossaad B, et al. Evaluation of Glandular Liposculpture as a Single Treatment for Grades I and II Gynaecomastia. Aesthetic Plast Surg. Oct 2018;42(5):1222-1230.
- American Society of Plastic Surgeons. Position Paper: Gynecomastia. Adopted October 1995.
- American Society of Plastic Surgeons. Gynecomastia, male breast reduction. www.plasticsurgery.org.
- American Society of Plastic Surgeons. ASPS Recommended Insurance Coverage Criteria for Third-Party Payers: Gynecomastia. 2002 (affirmed 2015); https://www.plasticsurgery.org/Documents/Health-Policy/Positions/Gynecomastia_ICC.pdf
- Anzarut A, Guenther CR, Edwards DC and Tsuyuki RT. Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. Plast Reconstruction Surg, April 2007; 119(4): 1159-1166.
- Braunstein, Glenn D. Current concepts: Gynecomastia. The New England Journal of Medicine, February 18, 1993, Vol. 328, No. 7, pp. 490-495.
- Cakan N, Kamat D. Gynecomastia: evaluation and treatment recommendations for primary care providers. Clin Pediatr (Phila). 2007; 46(6):487-490.
- Colombo-Benkmann M, Buse B, Stern J, Herfarth C. Indications for and results of surgical therapy for male gynecomastia. American Journal of Surgery 1999. 178 (1): 60-63.
- Dickson, Gretchen. Gynecomastia. Am Fam Physician. 2012 Apr 1; 85 (7):716-722.
- Fagerlund A, Lewin R, Rufolo G, et al. Gynecomastia: A systematic review. J Plas Surg Hand Surg. Dec 2015; 49(6):311-318.
- Fan L, Yang X, Zhang Y and Jiang J. Endoscopic subcutaneous mastectomy for the treatment of gynecomastia: A report of 65 cases. Surg Laparosc Endosc Percutan Tech, June 2009; 19(3): e85-90.
- Ferri: Ferri’s Clinical Advisor: Instant Diagnosis and Treatment, 2003 edition, Breast lump, p. 954.
- Grabb and Smith’s Plastic Surgery, 5th edition, October 2007, pp. 754-757.
- Goes JC, Landecker A. Ultrasound-assisted lipoplasty (UAL) in breast surgery. Aesthetic Plast Surg. Jan-Feb 2002; 26 (1): 1-9.
- Goroll AH. Evaluation of Gynecomastia. In A. H. Goroll (Ed.), Primary Care Medicine, 4th ed., Baltimore: Lippincott Williams & Wilkins 2000, pp. 623-625.
- Holzmer SW, Lewis PG, Landau MJ, Hill ME. Surgical Management of Gynecomastia: A Comprehensive Review of the Literature. Plast Reconstr Surg Glob Open. 2020 Oct 29;8(10):e3161.
- Kanakis GA, Nordkap L, Bang AK, et al. EAA clinical practice guidelines-gynecomastia evaluation and management. Andrology. 2019; 7(6):778-793.
- Laituri CA, Garey CL, Ostlie DJ, et al. Treatment of adolescent gynecomastia. J Pediatr Surg, March 2010; 45(3): 650-654.
- Lapid O, Jolink F, Meijer SL. Pathological findings in gynecomastia: analysis of 5113 breasts. Ann Plast Surg 2015; 74:163.
- Lemaine V, Cayci C, Simmons PS, Petty P. Gynecomastia in adolescent males. Semin Plast Surg. 2013 Feb;27(1):56-61.
- Malhotra AK, Amed S, Bucevska M, Bush KL, Arneja JS. Do Adolescents with Gynecomastia Require Routine Evaluation by Endocrinology? Plast Reconstr Surg. 2018 Jul;142(1):9e-16e.
- McKinney P, Lewis VL Jr. Gynecomastia. Grabb and Smith’s Plastic Surgery, 5th edition, pp. 1249-1255.
- Nuzzi LC, Firriolo JM, Pike CM, et al. The Effect of Surgical Treatment for Gynecomastia on Quality of Life in Adolescents. J Adolesc Health. Dec 2018;63(6):759-765.
- Pensler JM, Delgado MA, et.al. Plastic Surgery for Gynecomastia. Medscape Dec 2012. www.emedicine.com/plastic/topic125.htm.
- Petty PM, Solomon M, Buchel EW, Tran NV. Gynecomastia: evolving paradigm of management and comparison of techniques. Plast Reconstr Surg. 2010; 125(5):1301-1308.
- Qutob O, Elahi B, et al. Minimally invasive excision of gynecomastia—a novel and effective surgical technique. Ann R coll Surg Engl, April 2010; 92(3): 198-200.
- Rohrich RJ, Ha RY, Kenkel JM, et al. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg. Feb 2003; 111 (2): 909-923; discussion 924-925.
- U.S. National Library of Medicine and the National Institutes of Health. Gynecomastia. www.nlm.nih.gov/medlineplus/ency/article/003165.htm.
Medical Policy Group, May 2003 (1)
Medical Policy Administration Committee, May 2003
Available for comment August 13-September 26, 2003
Medical Policy Group, November 2004
Medical Policy Group, May 2006 (1)
Medical Policy Group, May 2007 (1)
Medical Policy Group, November 2008 (1)
Medical Policy Group, May 2010 (1) Key Points updated, references added
Medical Policy Group, May 2011 (3); Key Points and References updated
Medical Policy Group, November 2011 (1) Update to Key Points; no change in policy statement
Medical Policy Group, July 2013 (1) Update to References; no change in policy statement
Medical Policy Panel, October 2014
Medical Policy Group, February 2015 (3): Updates to Description, Key Points, and References. No change to policy statement.
Medical Policy Panel, February 2016
Medical Policy Group, April 2016 (2): 2016 Updates to Description, Key Points, Approved by Governing Bodies, and References; no change in policy statement.
Medical Policy Panel, February 2017
Medical Policy Group, March 2017 (7): 2017 Review complete, no new literature to include. No change in policy statement.
Medical Policy Panel, February 2018
Medical Policy Group, March 2018 (7): 2018 Update to Key Points, no new literature to include. No change in policy statement.
Medical Policy Panel, February 2019
Medical Policy Group, March 2019 (7): 2018 Update to Key Points and References. No change in policy statement.
Medical Policy Panel, February 2019
Medical Policy Group, March 2019 (7): 2020 Literature review complete. No updates to Key Points, Description, or References. No changes to policy statement.
Medical Policy Panel, February 2021
Medical Policy Group, February 2021 (7): Update to Key Points and References. Policy Statement updated with clarifications to required criteria. Coverage criteria for mastectomy for gynecomastia in adolescents update: Mastectomy for gynecomastia may be considered medically necessary adolescent males (≤18 years of age) with symptoms that have persisted for at least two years. Removed “drug related gynecomastia” from being considered not medically necessary and clarified criteria for when considered covered. Available for comment February 22, 2021 through April 8, 2021.
Medical Policy Panel, February 2022
Medical Policy Group, February 2022 (7): Update to Key Points and References. No change in policy statement.
This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
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As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.
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Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:
- In accordance with generally accepted standards of medical practice; and
- Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
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