Coverage Policy Manual
Policy #: 1998074
Category: Surgery
Initiated: February 1998
Last Review: May 2018
  Mastectomy, Male Gynecomastia

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. Bilateral gynecomastia may be associated with any of the following:
 
    • An underlying hormonal disorder (ie, conditions causing either estrogen excess or testosterone deficiency such as liver disease or an endocrine disorder)
 
    • An adverse effect of certain drugs
 
    • Obesity
 
    • Related to specific age groups, ie,
        • 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/
Coverage:
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.

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.

CPT/HCPCS:
19300Mastectomy for gynecomastia

References: Benkmann M, Buse B, Stern J, et al.(1999) Indications for and results of surgical therapy for male gynecomastia. Am J Surg 1999; 178:60-3.

Bower R, Bell MJ, Ternberg JL.(1976) Management of breast lesions in children and adolescents. J Ped Surg 1976; 11:337-46.

Fagerlund A, Lew in R, Rufolo G, et al.(2015) Gynecomastia: A systematic review. J Plast Surg Hand Surg. Dec 2015;49(6):311-318. PMID 26051284

Glass AR.(1994) Gynecomastia. Endocrinol Metab Clin N Am 1994; 23:825-837.

Mahoney, CP.(1990) Adolescent gynecomastia. Ped Clin N Am 1990; 37:1389-1404.


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2019 American Medical Association.