Anthem Blue Cross Connecticut CG-SURG-88 Mastectomy for Gynecomastia Form

This document addresses mastectomy performed for the treatment of gynecomastia. Gynecomastia is the unilateral or bilateral enlargement of male breast tissue attributed mainly to proliferation of ductular elements and not merely excessive breast tissue. Mastectomy for gynecomastia is a surgical procedure performed to remove glandular breast tissue from a male with enlarged breasts.

Note: Please see the following related documents for additional information:

• CG-SURG-71 Reduction Mammaplasty
• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect.

Note: Not all benefit contracts include benefits for reconstructive services as defined by this document. Benefit language supersedes this document.

Clinical Indications

Medically Necessary:

Mastectomy (including reconstruction if necessary) for gynecomastia in males over the age of 18, or 18 months after the end of puberty, whichever is younger, is considered medically necessary when the following criteria are met:

1. The tissue to be removed is glandular breast tissue and not the result of obesity, adolescence, or reversible effects of a drug treatment which can be discontinued (this would include drug-induced gynecomastia remaining unresolved 6 months after cessation of the causative drug therapy); and
2. Appropriate diagnostic evaluation has been done for possible underlying etiology; and
3. The individual has pain or tenderness directly related to the breast tissue (documented in the medical record) which has a clinically significant impact upon activities of daily living and has been refractory to a 3 month trial of analgesics or anti-inflammatory agents; and
4. Pre-operative photographs are provided.

Mastectomy for gynecomastia is considered medically necessary, regardless of age, when there is legitimate concern that a breast mass may represent breast carcinoma. Mammography may be of value to determine the need for surgery in some instances.

Reconstructive:
Mastectomy (including reconstruction if necessary) for gynecomastia in males over the age of 18, or 18 months after the end of puberty, whichever is younger, is considered reconstructive if it does not meet the medical necessary criteria above and is for drug-induced gynecomastia that does not resolve by 6 months after the cessation of drug therapy. Examples of some agents associated with the occurrence of gynecomastia are listed in the Discussion/General Information section of this document (not an all-inclusive list).

Not Medically Necessary:

Mastectomy for gynecomastia is considered not medically necessary when the above criteria are not met.

The use of liposuction to perform mastectomy for gynecomastia is considered not medically necessary.