Blue Cross Blue Shield Policy for Gyno Removal

[Stout1]

TweetBlueCross BlueShield of Tennessee Medical Policy Manual
Mastectomy for Gynecomastia

DESCRIPTION

Gynecomastia, enlargement of the male breast, occurs at times of male hormonal change during infancy, adolescence and old age. Male breast enlargement can be caused by medications, physiologic states, and medical conditions, which alter the balance of androgen and estrogen. Approximately 40-65% of boys develops some degree of gynecomastia during puberty. This physiological pubertal form of gynecomastia usually resolves spontaneously within 2 years and rarely requires hormonal or surgical treatment. Small swellings (less than 4 cm in diameter) resolve within 3 years without therapy in 90% of these cases. Enlargement sufficient to cause embarrassment and social disability occurs in fewer than 10% of those affected by puberty related gynecomastia. While it is not necessary to carry out a thorough diagnostic investigation in every case of gynecomastia, the presence of an underlying tumor (breast and testicular) needs to be excluded. Mastectomy for gynecomastia is a surgical procedure performed to remove breast glandular tissue from a male with enlarged breasts.

POLICY

Mastectomy for gynecomastia in a male may be considered medically necessary if all of the medical appropriateness criteria are met. (See Medical Appropriateness below.)

Mastectomy for gynecomastia is considered cosmetic for conditions specified under medical appropriateness.

MEDICAL APPROPRIATENESS

Mastectomy for gynecomastia is considered medically appropriate if all of the following criteria are met:

Gynecomastia has persisted longer than three (3) years post documented presentation to a physician; and

Gynecomastia is striking (greater than 4 cm in diameter) and causes serious emotional disturbance; and

The tissue for removal is glandular tissue (histologic examination of tissue removed is required). The pathology report must state that 4 cm or more of glandular tissue was removed.

Mastectomy for Gynecomastia is considered cosmetic for any of the following conditions:



Breast enlargement resulting from obesity; or


Breast enlargement resulting from drug treatment which can be discontinued; or


Removal of fatty tissue alone.

SOURCES

American Academy of Family Physicians. (2002, July). Gynecomastia: When Breast Form in Males. Retrieved September 20, 2002 from https://familydoctor.org/handouts/080.html.

American Society of Plastic and Reconstructive Surgeons. (1998). Lipoplasty. Retrieved September 20, 2002 from https://www.guideline.gov/FRAMESETS/g...g=gynecomastia.

American Society of Plastic Surgeons, (n. d.). Gynecomastia, male breast reduction. Retrieved September 20, 2002 from https://www.plasticsurgery.org/surger...necomastia.cfm.

Bowers, S. P., Pearlman, N. W., McIntyre, R. C., Finlayson, C. A., Huerd, S. (1998). Cost-effective management of gynecomastia. American Journal of Surgery. 176 (6): 638-641. Abstract retrieved August 17, 1999 from PubMed database.

Bullmann, C., Jockenhovel, F. (1998). Gynecomastia in men. Fortschritte Der Medizin. 116 (35-36): 18-22. Abstract retrieved August 17, 1999 from PubMed database.

Colombo-Benkmann, M., Buse, B., Stern, J., Herfarth, C. (1999). Indications for and results of surgical therapy for male gynecomastia. American Journal of Surgery. 178 (1): 60-63. Abstract retrieved March 29, 2001 from PubMed database.

Goroll, A.H. (2000). Evaluation of Gynecomastia. In A. H. Goroll (Ed.), Primary Care Medicine, (4th ed., pp. 623-625). Baltimore: Lippincott Williams & Wilkins.

Kauf, E. (1998). Gynecomastia in childhood. Pathological causes unusual but serious. Fortschritte Der Medizin. 116 (35-36): 23-26. Abstract retrieved August 17, 1999 from PubMed database.

Medical policy reference manual. [Computer software]. (1995, December). Mastectomy for gynecomastia. (7.01.13). Washington, DC: BlueCross BlueShield Association.

Sher, E. S., Migeon ,C. J., Berkovitz, G. D. (1998). Evaluation of boys with marked breast development at puberty. Clinical Pediatrics (Philadelphia). 37 (6): 367-371. Abstract retrieved August 17, 1999 from PubMed database.

EFFECTIVE DATE


10/31/2002


Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.

[yamaha147]

Tweetinteresting