MEDICAL POLICY

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DESCRIPTION
SCOPE
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APPENDIX
HISTORY

Mastectomy for Gynecomastia

Number 7.01.521

Effective Date March 11, 2013

Revision Date(s) 03/11/13; 01/06/12; 03/08/11; 02/09/10; 02/10/09; 04/08/08; 06/12/07; 06/14/05; 11/12/02; 11/05/97

Replaces 7.01.13

Policy

Malignant (cancer) mastectomy indications

Mastectomy surgery for gynecomastia may be considered medically necessary for diagnosed malignancy (cancer) of the breast(s) regardless of age.

Non-malignant (not cancer) mastectomy indications

Mastectomy surgery for gynecomastia may be considered medically necessary for non-malignant (not cancer) indications according to the criteria for adults and adolescents listed below:

Adults and Adolescents – must meet ALL criteria:

  • Glandular breast tissue is causing a physical functional impairment AND
  • Unilateral or bilateral Grade III or Grade IV gynecomastia is present (per modified McKinney and Simon, Hoffman and Kohn scales - See Practice Guidelines and Position Statements) AND:
  • Persists 2 years after pathological causes are ruled out; OR
  • Persists after 2 years of unsuccessful medical treatment for pathological causes.

AND

  • Pain and discomfort due to the distention and tightness from the hypertrophied breast(s) has not responded to medical management.

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

Liposuction as a treatment of gynecomastia is considered investigational.

Related Policies

10.01.514

Cosmetic and Reconstructive Services

Policy Guidelines

Medical necessity is based on the presence of a functional impairment. Typically no functional impairment is associated with gynecomastia. Therefore, determination of coverage eligibility for the surgical treatment of gynecomastia may require consideration of whether or not such surgery would be considered either essentially cosmetic in nature or reconstructive. (See Related Policies for further discussion of functional impairment, and general concepts of reconstructive and cosmetic services.)

The following definitions apply to this policy:

Cosmetic: In this policy, cosmetic services are those which are primarily intended to preserve or improve appearance. Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient’s appearance or self-esteem.

Physical Functional Impairment: In this policy, physical functional impairment means a limitation from normal (or baseline level) of physical functioning that may include, but is not limited to, problems with ambulation, mobilization, communication, respiration, eating, swallowing, vision, facial expression, skin integrity, distortion of nearby body parts or obstruction of an orifice. The physical functional impairment can be due to structure, congenital deformity, pain, or other causes. Physical functional impairment excludes social, emotional and psychological impairments or potential impairments.

Reconstructive Surgery: In this policy, reconstructive surgery refers to surgeries performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function.

Description

Gynecomastia is the benign enlargement of the male breast. The cause of enlargement may be due to increased adipose tissue, glandular tissue, fibrous tissue, or a combination of all three. The condition can be bilateral or unilateral. Clinically defined, “true gynecomastia” is the presence of an abnormal development of glandular tissue that may appear as a palpable rubbery or firm mass extending concentrically from the nipples. The condition known as pseudogynecomastia, or lipomastia, is characterized by fat deposition (adipose tissue) without glandular proliferation. (1) Pathological gynecomastia is breast enlargement due to a pathological process. The following are examples and not all inclusive:

  • An underlying hormonal disorder (i.e., conditions causing either estrogen excess or testosterone deficiency such as liver disease or an endocrine disorder);
  • A side effect of certain drugs (i.e., hormone therapy for prostate cancer, anabolic steroids, cimetidine, etc.);
  • Obesity;
  • Related to specific age groups, for example;
  • Neonatal gynecomastia, related to the action of maternal or placental estrogens;
  • Adolescent gynecomastia, which consists of transient, bilateral breast enlargement, which may be tender;
  • Gynecomastia of aging, related to the decreasing levels of testosterone and relative estrogen excess.

Treatment of gynecomastia involves consideration of the primary cause. For example, effective therapies for the underlying etiology may include treatment of a hormonal disorder, cessation of the medication causing the gynecomastia or weight loss. Adolescent gynecomastia may resolve with aging.

Prolonged gynecomastia causes periductal fibrosis and stromal hyalinization, which prevents regression of the breast tissue. Surgical removal of the fibrous breast tissue, using either surgical excision (mastectomy) or liposuction may be considered if the above conservative therapies are not effective or possible and the gynecomastia does not resolve spontaneously or with aging.

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

Contractual definitions of the scope of reconstructive services that may be eligible for coverage vary. Categories of conditions that may be included as part of the contractual definition of reconstructive services include some or all of the following:

  • Post-surgery
  • Accidental trauma or injury
  • Diseases
  • Congenital anomalies
  • Anatomic variants
  • Post-chemotherapy

For example, adolescent gynecomastia may be considered an anatomic variant, while gynecomastia related to liver disease would be considered secondary to a disease process.

Determinations of whether a proposed therapy would be considered reconstructive or cosmetic should always be interpreted in the context of the specific benefits language. State or federal mandates may also dictate coverage decisions.

Rationale

This policy was originally created in 1997 and has been updated based on searches of the MEDLINE database. The most recent literature search was performed for the period of December 2011 through December 2012. The following is a summary of the key findings since the policy was created to date.

Men who are receiving hormone therapy for prostate cancer may have gynecomastia as a side effect that will potentially reverse after treatment stops. Prophylactic radiotherapy has been shown to decrease the incidence of hormone induced gynecomastia by more than 50%. An alternative course of action, which may be more convenient for the patient, is the prophylactic use of tamoxifen. Tamoxifen may also mitigate or resolve gynecomastia during its early or proliferative phase. In severe long-standing gynecomastia, surgery is warranted since medical therapies are less likely to succeed. (2)

Henley noted that most cases of male prepubertal gynecomastia are classified as idiopathic. However, he investigated possible causes of gynecomastia in three prepubertal boys who were otherwise healthy and had normal serum concentrations of endogenous steroids. In all three boys, gynecomastia coincided with the topical application of products that contained lavender and tea tree oils. Gynecomastia resolved in each patient shortly after the use of products containing these oils was discontinued. Furthermore, studies in human cell lines indicated that the two oils had estrogenic and antiandrogenic activities. He concluded that repeated topical exposure to lavender and tea tree oils probably caused prepubertal gynecomastia in these boys. (3)

Rosen et al. looked at obesity as a root cause of gynecomastia and the role of obesity in persistent gynecomastia on psychological distress in adolescent males. This retrospective study reviewed demographics and surgical outcomes of adolescents with gynecomastia comparing obese/overweight to normal weighted patients. Between 1997-2008. Sixty-nine patients were identified with male “breasts” from database screening. By BMI criteria, 51% were obese, 16% overweight and 33% normal-weighted. Major complications occurred in 4 patients (5.8%); minor complications in 19 (27.5%). Potential causes other than obesity were found in 27%. Obese patients required more extensive operations (P = 0.009). Obese adolescents suffer greater psychological impact preoperatively (P = 0.02) and have no difference in satisfaction (P = 0.47) or complication rates (P = 0.33) than normal-weighted patients. The authors concluded that obesity should not be used as an absolute contraindication to gynecomastia surgery.(4)

Koshy and colleagues questioned the routine pathologic examination of breast tissue that is excised for adolescent gynecomastia, given the benign nature of the condition. They conducted a retrospective chart review to examine the incidence of pathologic abnormalities in patients 21 years or younger who had undergone subcutaneous mastectomy for gynecomastia. A literature review was also performed to determine the historical prevalence of cases of atypia or malignancy in cases of adolescent gynecomastia. Finally, an informal survey was performed of major children's hospitals regarding their practice of pathologic examination for adolescent gynecomastia. The chart review demonstrated that over the past 10 years, 81 patients with gynecomastia underwent subcutaneous mastectomy. All cases were negative for malignancy, with only one case of cellular atypia. They found that the literature has historically reported six cases of carcinoma and five cases of atypia. Of 22 survey respondents, all either routinely performed or required pathologic examination of breast tissue excised for gynecomastia. The out-of-pocket cost for self-pay patients to perform pathologic examinations has been quoted at $1268 for bilateral cases. They concluded that the incidence of malignancy or abnormal pathology associated with gynecomastia tissue in the adolescent male is extremely low, and given the associated costs, the pathologic examination of breast tissue excised for gynecomastia in individuals 21 years of age or younger should be neither routinely performed nor required but should be performed only when desired by either the patient, the patient’s family, or the managing physician.(5)

Several surgical approaches have been described in the literature for removing glandular breast tissue. Procedures to treat gynecomastia include direct excision (mastectomy), liposuction, ultrasound-assisted liposuction or a combination of these.

Lanitis and colleagues studied gynecomastia surgical outcomes at a single institution from 1998 through 2007. A total of 748 males were referred to the center for breast symptoms. From that total, 65 males (102 breasts) with a median age of 26 years old had surgery for gynecomastia. A total of 82 breasts were treated with mastectomies and 22 with skin reduction. The procedures carried out were subcutaneous mastectomy or breast disk excision, with or without skin reduction. Major post-surgical complications consisted of hematomas requiring evacuation, wound infection; partial nipple necrosis, dehiscence, and wound break down occurred in 12 breasts. The authors concluded that after excluding malignancy, most males with gynecomastia can be managed conservatively. Conservative treatments could include counseling for reassurance, weight reduction and medications. (6)

Li and colleagues analyzed the surgical approaches to the treatment of gynecomastia and outcomes over a 10-year period. Retrospective data was collected from patients undergoing surgical correction of gynecomastia at one hospital in Taiwan from 2000-2010. The data were analyzed for etiology, stage of gynecomastia, surgical technique, complications, risk factors, and revision rate. The surgical result was evaluated with self-assessment questionnaires. A total of 41 patients with 75 operations were included. Techniques included subcutaneous mastectomy alone or with additional ultrasound-assisted liposuction (UAL) and isolated UAL. The surgical revision rate for all patients was 4.8%. The skin-sparing procedure gave good surgical results in grade IIb and grade III gynecomastia with low revision and complication rates. The self-assessment report revealed a good level of overall satisfaction and improvement in self-confidence (average scores 9.4 and 9.2, respectively, on a 10-point scale). The authors conclude that the treatment of gynecomastia requires an individualized approach, with their proposal that subcutaneous mastectomy combined with UAL could be used as the first choice for surgical treatment of grade II and III gynecomastia.(7)

Rohrich et al. suggest that ultrasound-assisted suction lipectomy as a treatment for gynecomastia reduces scarring and improves removal of fibrous male breast tissue. (8) There is a lack of evidence in peer-reviewed scientific literature that suction lipectomy (liposuction) whether ultrasound-assisted or not does more than remove adipose tissue. Surgical intervention by mastectomy is the more definitive treatment to remove the glandular breast tissue in males with symptomatic gynecomastia.

Ongoing Clinical Trials

No randomized controlled trials (RCTs) were identified that addressed surgery for gynecomastia in a search of the online site ClinicalTrials.gov in December 2012.

Practice Guidelines and Position Statements

The American Society of Plastic Surgeons (ASPS) issued a practice criteria for third-party payers (9) The ASPS recommends describing the severity of gynecomastia using the following scale, that was adapted from the McKinney and Simon, Hoffman and Kohn scales:

Grade I

Small breast enlargement with localized button of tissue that is concentrated 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 present

Grade IV

Marked breast enlargement with skin redundancy and feminization of the breast

According to the ASPS, in adolescents, surgical treatment for unilateral or bilateral grade II or grade III gynecomastia may be appropriate if the gynecomastia persists for more than 1 year after pathological causation is ruled out (or 6 months if grade IV) and continues after 6 months of medical treatment is unsuccessful. In adults, surgical treatment for unilateral or bilateral grade III or grade IV gynecomastia may be appropriate if the gynecomastia persists for more than 3-4 months after pathological causation is ruled out and continues after 3-4 months of medical treatment is unsuccessful. The ASPS also indicates surgical treatment of gynecomastia may be appropriate when distention and tightness cause pain and discomfort. (9)

This policy is more restrictive than the recommendations made by ASPS.

Medicare National Coverage

No national coverage determination

References

  1. Carlson H. Approach to the Patient with Gynecomastia. J Clin Endocrinol Metab, January 2011, 96(1):15–21.
  2. Dobs A, Darkes MJ. Incidence and management of gynecomastia in men treated for prostate cancer. J Urol 2005;174(5):1737-42.
  3. Henley DV, Lipson N, Korach KS et al. Prepubertal gynecomastia linked to lavender and tea tree oils. N Engl J Med. 2007;356(5):479-85.
  4. Rosen H, Webb ML, DiVasta AD, et al. Adolescent gynecomastia: not only an obesity issue. Ann Plast Surg. 2010 May; 64(5):688-90.
  5. Koshy JC, Goldberg JS, Wolfswinkel EM et al. Breast cancer incidence in adolescent males undergoing subcutaneous mastectomy for gynecomastia: is pathologic examination justified? A retrospective and literature review. Plast Reconstr Surg. 2011; 127(1):1-7.
  6. Lanitis S, Starren E, Read J et al. Surgical management of Gynaecomastia: outcomes from our experience. Breast. 2008; 17(6):596-603.
  7. Li CC, Fu JP, Chang SC, Chen TM, Chen SG. Surgical Treatment of Gynecomastia: Complications and Outcomes. Ann Plast Surg. 2012 Nov; 69(5):510-5.
  8. Rohrich RJ, Ha RY, Kenkel JM et al. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg 2003; 111(2):909-25.
  9. American Society of Plastic Surgeons (ASPS); Position Paper: Practice Parameters Gynecomastia. 2004. Arlington Heights IL. Available at: http://www.plasticsurgery.org/Medical_Professionals/Health_Policy_and_Advocacy/Health_Policy_Resources/Evidence-based_GuidelinesPractice_Parameters.html Last accessed February 26, 2013.
  10. BlueCross BlueShield Association Medical Policy Reference Manual Surgical Treatment of Bilateral Gynecomastia. Medical Policy Reference Manual, Policy No. 7.01.13, 2012.
  11. Reviewed by two practicing pediatricians. February 2013.

Coding

Codes

Number

Description

CPT

19300

Mastectomy for gynecomastia

 

19304

Mastectomy, subcutaneous

 

15877

Suction assisted lipectomy; trunk

ICD-9 Procedure

85.31

Unilateral reduction mammaplasty

 

85.32

Bilateral reduction mammaplasty (for gynecomastia)

ICD-9 Diagnosis

611.1

Hypertrophy of breast (includes gynecomastia)

 

611.71

Mastodynia

 

758.7

Klinefelter’s syndrome

HCPCS

 

N/A

ICD-10-CM
(effective 10/01/14)

N62

Hypertrophy of breast (includes gynecomastia)

ICD-10-PCS
(effective 10/01/14)

0HBT0ZZ, 0HBT3ZZ, 0HBU0ZZ, 0HBU3ZZ, 0HBV0ZZ, 0HBV3ZZ

Surgical, excision, breast, coded by body part (right, left or bilateral) and approach (open or percutaneous)

Type of Service

Surgery

 

Place of Service

Inpatient

 

Appendix

N/A

History

Date

Reason

11/05/97

Add to Surgery Section - New Policy

11/12/02

Replace Policy - Policy reviewed without literature review; new review date only.

02/10/04

Replace Policy - Policy status changed from AR.7.01.13 to PR.7.01.121. Remains medically necessary.

09/01/04

Replace Policy - Policy renumbered from PR.7.01.121. No changes to dates.

06/14/05

Replace Policy - Policy reviewed without literature review; new review date only. Status changed to AR.

06/09/06

Disclaimer and Scope update - No other changes.

02/26/07

Update Codes - No other changes.

06/12/07

Replace Policy - Policy statement expanded to indicate removal of glandular tissue as cosmetic in the absence of a physical functional impairment; definitions of physical functional impairment, cosmetic and reconstructive surgery added to Benefit Application section. Policy status changed from AR to PR.

04/08/08

Replace Policy - Policy reviewed with literature search; no change to the policy statement. Requirement of histologic exam of tissue was deleted from Policy Guidelines. Reference added.

02/10/09

Replace Policy - Policy reviewed with literature search. Policy statement updated to remove the cosmetic statement and include “not medically necessary” for all indications relating to Mastectomy for gynecomastia.

02/09/10

Replace Policy - Policy updated with literature search. No change to policy statement.

03/08/11

Replace Policy - Policy updated with literature search. No change to policy statement.

09/23/11

Related Policies updated; 10.01.514 added.

01/06/12

Replace Policy – Policy updated with literature search. No change in policy statement.

03/11/13

Replace Policy. Policy split into malignant and non-malignant sections. Policy section has ASPS grades III-IV added for criteria to be met for unilateral or bilateral gynecomastia, added duration of symptoms is 2 years and pain is unresponsive to medical management. Liposuction added as investigational. Definitions moved to Policy Guidelines section. Added the condition can be bilateral or unilateral to the Description section. Benefit application section revised. Description and Rationale sections updated based on a literature review through December 2012; and clinical vetting with 2 pediatricians. Policy statement changed as noted.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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