CAM 70113

Surgical Treatment of Bilateral Gynecomastia

Category:Surgery   Last Reviewed:August 2018
Department(s):Medical Affairs   Next Review:August 2019
Original Date:August 2013    

Description
Bilateral gynecomastia is a benign enlargement of the male breast, either due to increased adipose tissue, glandular tissue, fibrous tissue, or a combination of all 3. Surgical removal of the breast tissue, using either surgical excision or liposuction, may be considered if conservative therapies are not effective or possible.

For individuals with bilateral gynecomastia who receive surgical treatment, the evidence includes case series. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related morbidity. Because there are no randomized controlled trials on surgical treatment of bilateral gynecomastia, it is not possible to determine whether surgical treatment improves symptoms or functional impairment. Conservative therapy should adequately address any physical pain or discomfort, and gynecomastia does not typically cause functional impairment. The evidence is insufficient to determine the effect of the technology on health outcomes.  

Background  
Bilateral gynecomastia is a benign enlargement of the male breast, either due to increased adipose tissue, glandular tissue, fibrous tissue, or a combination of all 3. Bilateral gynecomastia may be associated with any of the following:

  • An underlying hormonal disorder (i.e., conditions causing either estrogen excess or testosterone deficiency such as liver disease or an endocrine disorder)
  • An adverse effect of certain drugs
  • Obesity
  • Related to specific age groups, i.e.,
    • Neonatal gynecomastia, related to 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 underlying cause. For example, treatment of the underlying hormonal disorder, cessation of drug therapy, or weight loss may all be effective therapies. Gynecomastia may also resolve spontaneously, and adolescent gynecomastia may resolve with aging. 

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

Regulatory Status  
Surgical procedures are not regulated by the U.S. Food and Drug Administration 

Policy
Surgical treatment of gynecomastia is considered MEDICALLY NECESSARY for either of the following conditions:

  • Klinefelter's Syndrome
  • Either pubertal (adolescent) onset gynecomastia that has persisted for at least two years OR post pubertal-onset gynecomastia that has persisted for one year, whenALL of the following criteria are met:
    • Male is over 18 years of age with significant breast tissue present as documented in the historical medical record.
    • Glandular breast tissue confirming true gynecomastia is documented by mammography and/or tissue pathology.
    • The gynecomastia is classified as Grade IV per the American Society of Plastic Surgeons classification. (See Practice Guidelines and Position Statements)
    • The use of potential gynecomastia-inducing drugs and substances has been identified and discontinued for at least one year, when medically appropriate, before surgery has been considered.  (See reference chart)
    • Hormonal causes, including hyperthyroidism, estrogen excess, prolactinomas and hypogonadism have been excluded by appropriate laboratory testing and, if present, have been treated for at least 12 months before surgery has been considered.
    • Excessive breast development is not due to non-covered therapies or illicit drugs, e.g., anabolic steroid or marijuana.
    • Member is within 20% of ideal body weight.

Surgical treatment of gynecomastia for ANY other indication is considered NOT MEDICALLY NECESSARY.

The use of liposuction to perform mastectomy for gynecomastia is considered NOT MEDICALLY NECESSARY.

Rationale    
Coverage eligibility for treatment of bilateral gynecomastia is largely a contract/benefits issue related to the distinction between cosmetic and reconstructive services. The surgical procedure may involve surgical excision (i.e., mastectomy). More recently, liposuction has been used.1,2 In some instances, adolescent gynecomastia may be reported as tender or painful, and the presence of these symptoms may be presented as a rationale for the medical necessity of surgical treatment. However, the pain associated with adolescent gynecomastia is typically self-limiting or responds to analgesic therapy.

To demonstrate improvement in health outcomes, controlled trials are needed that report clinically important outcomes such as improvement in functional status. No such trials were identified through literature search. A systematic review published in 2015 included 14 studies on the treatment of gynecomastia.3 None was randomized, all were judged to be at high risk of bias, and the body of evidence was determined to be of very low quality by GRADE criteria.

SUMMARY OF EVIDENCE
For individuals with bilateral gynecomastia who receive surgical treatment, the evidence includes case series. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related morbidity. Because there are no randomized controlled trials on surgical treatment of bilateral gynecomastia, it is not possible to determine whether surgical treatment improves symptoms or functional impairment. Conservative therapy should adequately address any physical pain or discomfort, and gynecomastia does not typically cause functional impairment. The evidence is insufficient to determine the effect of the technology on health outcomes 

PRACTICE GUIDELINES AND POSITION STATEMENTS
The American Society of Plastic Surgeons (ASPS) issued practice criteria for third-party payers in 2002.4 ASPS classified gynecomastia using the following scale, which 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 ASPS, in adolescents, surgical treatment for unilateral or bilateral grade II or III gynecomastia may be appropriate if the gynecomastia persists for more than 1 year after pathologic causation is ruled out (or 6 months if grade IV) and continues after 6 months if medical treatment is unsuccessful. In adults, surgical treatment for unilateral or bilateral grade III or IV gynecomastia may be appropriate if the gynecomastia persists for more than 3 or 4 months after pathologic causation is ruled out and continues after 3 or 4 months of medical treatment that is unsuccessful. ASPS also indicated that surgical treatment of gynecomastia may be appropriate when distention and tightness cause pain and discomfort. 

U.S. PREVENTIVE SERVICES TASK FORCE RECOMMENDATIONS
Not applicable. 

ONGOING AND UNPUBLISHED CLINICAL TRIALS
A search of ClinicalTrials.gov in January 2017 did not identify any ongoing or unpublished trials that would likely influence this review.

References  

  1. Rohrich RJ, Ha RY, Kenkel JM, et al. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg. Feb 2003;111(2):909-923; discussion 924-905. PMID 12560721
  2. Goes JC, Landecker A. Ultrasound-assisted lipoplasty (UAL) in breast surgery. Aesthetic Plast Surg. Jan-Feb 2002;26(1):1-9. PMID 11891589
  3. Fagerlund A, Lewin R, Rufolo G, et al. Gynecomastia: A systematic review. J Plast Surg Hand Surg. Dec 2015;49(6):311-318. PMID 26051284
  4. American Society of Plastic Surgeons. ASPS Recommended Insurance Coverage Criteria for Third-Party Payers. 2002; http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/insurance/Gynecomastia-Insurance-Coverage.pdf. Accessed January 26, 2017. 

Coding Section

Codes Number Description
CPT 19300 Mastectomy for gynecomastia 
ICD-9 Procedure 85.31 Unilateral reduction mammoplasty
  85.32 Bilateral reduction mammoplasty (for gynecomastia) 
ICD-9 Diagnosis 611.1 Hypertrophy of breast (includes gynecomastia) 
HCPCS No Code  
 ICD-10-CM (effective 10/01/15)   Not medically necessary for all relevant diagnoses 
  N62  Hypertrophy of breast (includes gynecomastia) 
ICD-10-PCS (effective 10/01/15)    ICD-10-PCS codes are only used for inpatient services. 
  0HBT0ZZ, 0HBT3ZZ, 0HBU0ZZ, 0HBU3ZZ, 0HBV0ZZ, 0HBV3ZZ Surgical, excision, breast, code by body part (right, left or bilateral) and approach (open or percutaneous) 
Type of Service  Surgery   
 Place of Service  Inpatient  

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.  

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

08/07/2018 

Annual review, no change to policy intent. 

08/'24/2017 

Annual review, no change to policy intent. Updating background, description, rationale and references. 

08/11/2016 

Annual review, no change to policy intent. Updating background, description, rationale and references. 

06/13/2016 

Interim review, changing liposuction to perform mastectomy for gynecomastia from investigational to not medically necessary. No other changes made. 

09/30/2015 

Updated policy external to match internal. 

08/26/2015 

Annual review, no change to policy intent. Updated background, description, rationale and references. Added coding. 

08/04/2014

Annual review, no changes made.


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