Harvard Pilgrim Health Care Medical Policy

Gynecomastia Surgery STRIDEsm (HMO) MEDICARE ADVANTAGE

Subject: Gynecomastia Surgery

Background:

Gynecomastia is a benign proliferation of the male breast. It is caused by an imbalance in the ratio of male hormone (testosterone) to female hormone (estrogen). The condition is often associated with pain or tenderness and is characterized by growth of the glandular tissue or by an accumulation of fatty tissue deposits. Pathological gynecomastia is caused by conditions that decrease the production of testosterone or increase the activity of estrogen. Some specific conditions that are associated with gynecomastia include Klinefelter’s syndrome, hyperthyroidism, and hypogonadism.

Authorization:

Prior authorization from Harvard Pilgrim StrideSM (HMO) Medicare Advantage is required for all gynecomastia surgery procedures.

Policy and Coverage Criteria:

Harvard Pilgrim StrideSM (HMO) Medicare Advantage considers surgical treatment of gynecomastia as reasonable and medically necessary when EITHER of the following criteria are met:

• Documentation and photographs confirm that member has Klinefelter’s syndrome, OR
• Documentation confirms ALL of the following conditions:
  1. Member is male and 18 years or older; AND
  2. Physical examination, mammogram or tissue pathology confirms that breast tissue is glandular, not fatty tissue; AND
  3. Member experiences tenderness or pain in breast tissue despite a 3-month trial of analgesic or non-steroidal anti-inflammatory drugs (NSAIDs); AND
  4. Grade III or IV gynecomastia (unilateral or bilateral) persists more than 1 year or persists after 6 months of unsuccessful medical treatment of pathologic gynecomastia; AND
  5. History excludes signs of significant liver disease (including alcohol abuse) AND
  6. History excludes exposure or use of medications or other substances (e.g. hormones, steroids, supplements, herbal products) as contributing factors to pathologic gynecomastia; AND
  7. Preoperative photographs are provided
• Note: Faxed photographs usually do not allow adequate assessment of the grade/extent of gynecomastia. Mailed or emailed copies of photographs are required.

Exclusions:

Harvard Pilgrim StrideSM (HMO) Medicare Advantage considers gynecomastia surgery as cosmetic for all other indications. In addition, HPHC does not cover gynecomastia surgery when:

• Psychological distress is the primary reason for surgery
• There is a history of substance abuse (e.g. marijuana, heroin, amphetamines), cirrhosis or chronic alcohol abuse, and/or use of supplements/herbal products/hormones that can cause gynecomastia, and these substances have not been prescribed by a licensed clinician to treat a medical condition
• Treatment is determined to be cosmetic (primarily to improve or reshape the member’s appearance)

Internal Use Only

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Harvard Pilgrim StrideSM (HMO) policies are based on medical science and relevant information including current Medicare coverage (including National and Local Coverage Determinations), Harvard Pilgrim medical policies, and Harvard Pilgrim StrideSM (HMO) Medicare Advantage Plan materials. These policies are intended to provide benefit coverage information and guidelines specific to the Harvard Pilgrim StrideSM (HMO) Medicare Advantage Plan. Providers are responsible for reviewing the CMS Medicare Coverage Center guidance; in the event that there is a conflict between this document and the CMS Medicare Coverage Center guidance, the CMS Medicare Coverage Center guidance will control.

Supporting Information:

Choi et al. (2017) conducted a smaller retrospective study to report on short-term surgical outcomes of gynecomastia for 71 adolescents out of 1454 patients.

All cases were bilateral and performed with liposuction on adolescents with a history of gynecomastia for over 3 years with psychological distress. 51 patients (71.8%) were classified as having a glandular type breast component. 14 patients (19.7%) had complications, but only 3 cases (4.2%) required revision. In conclusion, glandular type gynecomastia did not regress spontaneously so not only liposuction but also the surgical removal of the glandular tissue was necessary.

Brown et al. (2015) reviewed the surgical techniques in the treatment of gynecomastia. They stated that contemporary surgical techniques have become increasingly less invasive with the use of liposuction. However, the authors concluded that these techniques have been largely limited in their inability to address significant skin excess and ptosis.

Guidelines:

The American Society of Plastic Surgeons (ASPS) has adopted the following classification system for gynecomastia from the McKinney and Simon, Hoffman and Kohn Scale:

• Grade I – small breast enlargement with localized button of tissue around the areola
• Grade II – moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest
• Grade III – moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy
• Grade IV – marked breast enlargement with skin redundancy and feminization of the breast