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Point32Commercial Clinical Policy

Point32 Gynecomastia Surgery(Eff. beginning 1.1.24) Form


Gynecomastia Surgery

Notes: This policy considers gynecomastia surgery cosmetic and hence typically not covered for all indications not supported by CMS guidance or additional medical rationale.

Indications

(797444) Is the surgery based on an LCD for Cosmetic and Reconstructive Surgery (L39051) and Article for Billing and Coding: Cosmetic and Reconstructive Surgery (A58774) issued by CMS for Medicare Advantage plan members? 
(797445) Is the gynecomastia surgery intended solely for improvement or reshaping the member’s appearance? 

Contraindications

(797446) Is psychological distress the primary reason for the gynecomastia surgery? 
(797447) Does the patient have a history of substance abuse (e.g., marijuana, heroin, amphetamines), cirrhosis, or chronic alcohol abuse? 
(797448) Has the patient been using supplements, herbal products, or hormones that are not prescribed by a licensed clinician and that might have caused gynecomastia? 
YesNoN/A
YesNoN/A

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Effective Date

01/01/2024

Last Reviewed

11/16/2023

Original Document

  Reference



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.

Clinical Guideline Coverage Criteria

Harvard Pilgrim Health Care uses guidance from the Centers for Medicare and Medicaid Services (CMS) for coverage determinations for its Medicare Advantage plan members. CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs) and documentation included in the Medicare manuals are the basis for coverage determinations where available. For Harvard Pilgrim Health Care Medicare Advantage plan members, the following criteria is used:

  • LCD - Cosmetic and Reconstructive Surgery (L39051) (cms.gov)
  • Article - Billing and