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:

• 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. Drugs associated with gynecomastia include but are not limited to hormones (e.g., anabolic steroids, androgens and estrogens), antibiotics (e.g., metronidazole, ketoconazole), antiulcer medications (e.g., cimetidine), cardiovascular drugs (e.g., digoxin. spironolactone), and some psychoactive and chemotherapeutic agents
• Obesity
• An underlying pathologic condition. These may include Klinefelter syndrome, kidney or liver failure, and presence of testicular or pituitary tumors.
• Related to specific age groups, for example:
  • Neonatal gynecomastia, related to action of maternal or placental estrogens
  • Adolescent gynecomastia, which consists of transient, bilateral breast enlargement
  • 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 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.

Definitions

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:

• 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.

NOTE: Coverage may be subject to legislative mandates, including but not limited to the following, which applies prior to the policy statements:

• Minnesota Statute 62A.25 Reconstructive Surgery

I.   Surgery for gynecomastia may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following are met:

• Gynecomastia has persisted for at least:
  • 2 years if patient is younger than 18 years of age; OR
  • 1 year if patient is 18 years of age or older; AND
• Glandular breast tissue confirming true gynecomastia is documented on physical examination; AND
• Gynecomastia is classified as Grade II, III or IV per the American Society of Plastic Surgeons classification (See Definition above); AND
• Gynecomastia is associated with persistent breast discomfort despite the use of analgesics; AND
• Presence of an underlying pathologic process (e.g. breast, adrenal or testicular tumors, kidney or liver disease) has been ruled out; AND
• Use of potential gynecomastia-inducing drugs and substances has been identified and discontinued for at least one year, when medically appropriate; AND
• Hormonal causes have been excluded by appropriate laboratory testing and, if present, have been treated for at least one year prior to surgery. These include but are not limited to the following as confirmed by laboratory testing:
  • Hyperthyroidism 
  • Excess estrogen 
  • Prolactinomas 
  • Hypogonadism

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:

• To improve the appearance of the male breast or to alter the contours of the chest wall
• To remove excess adipose (fat) tissue (pseudogynecomastia)
• Use of liposuction to perform gynecomastia surgery

Documentation Submission:

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:

• Confirmation of diagnosis, symptoms, and medical therapy
• Laboratory test results if indicated
• Exclusion of secondary causes
• Photographs are required

Link to  Pre-Authorization Form:  https://www.bluecrossmn.com/sites/default/files/DAM/2021-12/BCBSMN-Pre-Auth-Request-fillable-X18509R07.pdf