Humana Gynecomastia Surgery Form

Description

Gynecomastia, excessive development of the glandular tissue of the male breast, may occur in infancy, adolescence or adulthood. The cause varies but may include endocrine disorders (hormonal imbalances), medication side effects, medical conditions or it may be idiopathic (unknown). Spontaneous regression of breast tissue occurs in most cases.

Surgical treatment for gynecomastia consists of a mastectomy, which is the excision (removal) of breast tissue. The surgery has two objectives: reconstruction of the male chest contour and histological clarification (lab evaluation) of any suspicious breast lesions. The consistency and grade of breast tissue, the individual’s age and presence of unilateral or bilateral breast development determine the need for surgery.

Page: 1 of 6

Gynecomastia Surgery Effective Date: 03/23/2023

Revision Date: 03/23/2023

Review Date: 03/23/2023

Policy Number: HUM-0437-016

Page: 2 of 6

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

A complete history and physical exam with appropriate diagnostic testing is generally performed prior to surgical intervention to determine the underlying cause of the gynecomastia. If due to obesity, mastectomy is not indicated, as the cause is fatty tissue (lipomastia, pseudogynecomastia), not breast tissue.

Coverage Determination

Humana members may be eligible under the Plan for gynecomastia surgery when the following criteria are met:

• Grade IV gynecomastia; AND
• Gynecomastia not due to the use of anabolic steroids, alcohol abuse or illegal drugs; AND
• Individual is 18 years of age or older, or growth is complete (adult testicular size attained10); AND
• Presence of a functional impairment* that has failed to respond to conservative treatment** and is adversely affecting activities of daily living, including both of the following:
  1. Chronic skin irritation not relieved or controlled by dermatological therapy and other prescribed medical treatment; AND
  2. Persistent severe pain despite the use of medically supervised analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs); AND
• Tissue to be removed is glandular breast tissue and not the result of obesity or puberty; AND ANY of the following indications:
  1. Gynecomastia persisting greater than 12 months despite treatment for a known underlying causative medical condition (eg, androgen deficiency, endocrine disorders, increased estrogen secretion, Klinefelter syndrome); OR
  2. Idiopathic gynecomastia persisting beyond 24 months when underlying hormonal or medical causes have been excluded by appropriate laboratory testing (eg, beta subunit human chorionic gonadotropin [HCG], estradiol, prolactin, testosterone, thyroid function studies); OR
  3. Medication-induced (eg, bicalutamide, cimetidine, human growth hormone, ketoconazole, nifedipine, spironolactone) gynecomastia that does not resolve after six months of cessation of the drug therapy

Functional impairment is defined as a direct and measurable reduction in physical performance of an organ or body part. Functional impairment does not include altered ability to participate in athletic, leisure, sport or social activities.

Page: 3 of 6

Gynecomastia Surgery Effective Date: 03/23/2023

Revision Date: 03/23/2023

Review Date: 03/23/2023

Policy Number: HUM-0437-016

Conservative treatment includes at least three consecutive months of medical management, under the direction of a health care professional within the past 12 months, and both of the following:

• Abstinence from anabolic steroids, alcohol abuse or illegal drugs; AND
• Compliance with medically prescribed topical or oral medication

Coverage Limitations

Humana members may NOT be eligible under the Plan for gynecomastia surgery for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for gynecomastia surgery using liposuction. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Additional information about gynecomastia may be found from the following websites:

Background

Gynecomastia Surgery Effective Date: 03/23/2023
Revision Date: 03/23/2023
Review Date: 03/23/2023
Policy Number: HUM-0437-016

Page: 4 of 6

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

American Society of Plastic Surgeons • National Library of Medicine

Medical Alternatives

Alternatives to gynecomastia surgery include, but may not be limited to, the following:

• Observation
• Prescription drug therapy

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.