This policy version was replaced June 27, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).
Gynecomastia is defined as benign proliferation of male breast glandular tissue. Individuals with increased breast tissue often have pseudogynecomastia, which is an accumulation of subareolar fat tissue rather than glandular tissue.
Gynecomastia may be due to a number of causative factors including one or more of the following:
Treatment of gynecomastia involves consideration of the underlying cause. For example, treatment of an underlying hormonal disorder, cessation of drug therapy, or weight loss may all be effective therapies depending on the cause of gynecomastia. Gynecomastia may also resolve spontaneously. Adolescent gynecomastia generally resolves with aging. Prolonged gynecomastia causes periductal fibrosis and stromal hyalinization, which prevent regression of the breast tissue. Although the prevalence of breast malignancy in patients with gynecomastia is low, a careful history and physical examination are required prior to surgery to rule out underlying pathology.
Grading System for Gynecomastia
The American Society of Plastic Surgeons has developed the following system of Classification for Gynecomastia, adapted from the McKinney and Simon, Hoffman and Kohn scales:
NOTE: Coverage may be subject to legislative mandates, including but not limited to the following, which applies prior to the policy statements:
I. Surgery for gynecomastia may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following are met:
II. Gynecomastia surgery in all other circumstances including but not limited to the following is considered COSMETIC as it is performed primarily to enhance or otherwise alter physical appearance without correcting or improving a physiological function:
Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorization when prior authorization is required. In addition, the following documentation must be submitted:
Link to Pre-Authorization Form: https://www.bluecrossmn.com/sites/default/files/DAM/2021-12/BCBSMN-Pre-Auth-Request-fillable-X18509R07.pdf
No additional statements.
Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.
Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.
Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.
Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.