Coverage Policies

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 11/24/2003 Title: Gynecomastia
Revision Date: 01/01/2020 Document: BI012:00
CPT Code(s): 19300, 19301, 19302, 19303, 19305, 19306,19307, 19316, 19318
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Gynecomastia is enlargement of the male breast to the same proportion as might be expected of the female breast.  It is a common occurrence during puberty and generally subsides spontaneously when hormonal maturation is complete.  Surgery for gynecomastia is covered under medical indications by preauthorization only.


Medical Statement

A.   Mastectomy is covered without prior authorization with diagnosis of breast cancer: (C50.011 – C50.929 and D05.00-D05.92).

a.    Without any of the above diagnosis codes for breast cancer, 19301 – 19307 require preauthorization. 

B.   Medical necessity for mastectomy for gynecomastia has not been demonstrated if the only reason is one of the following:

  1. psychological and sociological complaints:
    1. body image
    2. embarrassment
    3. inability to find comfortably fitting clothes
    4. poor social interaction
  2. inability to participate in physical activities, e.g.:
    1. gymnastics
    2. high impact aerobics
    3. running

C.   Coverage for mastectomy for gynecomastia will be considered if all of the following apply:

1.    Patient is over puberty

2.    Pseudogynecoma has been ruled out by any of the following:

a.    Mammography

b.    Ultrasonography

3.    Sub-areolar breast tissue at least four centimeters in diameter in a supine male

4.    Documented weight reduction trial of at least six months in a patient 25% or more over ideal body weight.

5.    Physical symptoms, including any of the following:

a.    painful breast distention and tightness

b.    symptoms of mastitis

c.    presence of a disk-shaped mass of mobile, rubbery-feeling glandular tissue beneath the nipple and areolar area

6.    Complete endocrine work-up to rule out any other causes of gynecomastia, including discontinuation of any of the following medications:

a.    estrogen

b.    gonadotropins

c.    prolactin stimulating agents

d.    testosterone

7.    Other causes of gynecomastia have been treated or ruled out, which include any of the following:

a.    alcoholism

b.    breast cancer

c.    liver disease

d.    lung cancer

e.    malnutrition

f.     medication use discontinued (unless discontinuation would endanger the life or health of the patient) and symptoms continue, including any of the following:

                                          i.    antidepressants

                                        ii.    calcium channel blockers

                                       iii.    corticosteroids

                                       iv.    D-Penicillamine

                                        v.    Histamine-2 receptor blockers

                                       vi.    Illicit drugs

                                      vii.    Inhibitors of testosterone synthesis or action

                                     viii.    neuroleptics

                                       ix.    opioids

                                        x.    thiazides

                                       xi.    spironolactone

g.    renal failure

h.    testicular insufficiency

i.      testicular tumor

j.      thyroid dysfunction

8.    Six month trial of conservative therapy, including all of the following:

a.    analgesics, daily

b.    consideration of drug therapy, including any of the following:

NOTE: “consideration” means that there must be documentation in the medical records of a thought process leading to a conclusion regarding the choice either to try or not to try drug therapy.

NOTE: Since the long-term effectiveness and safety of the following drugs in the treatment of idiopathic gynecomastia has not been established, these are recommended to be administered under the supervision of an endocrinologist skilled in this type of drug therapy.

                                      xii.    clomiphene citrate

                                     xiii.    dihydrotestosterone

                                    xiv.    Danazol

                                      xv.    tamoxifen

c.    nutritional and dietary intervention

d.    weight loss, if applicable

 

Codes Used In This BI:

19316

Suspension of breast

19318

Breast reduction (code revised eff 01-01-2021)

19300

Removal of breast tissue

19301

Partial mastectomy

19302

P-mastectomy w/ln removal

19303

Mast simple complete

19304

Mast subq

19305

Mast radical

19306

Mast rad urban type

19307

Mast mod rad


Reference

Addendum:

1.    Effective 03/01/2017: Clarification added that other mastectomy codes (19301 – 19307) are covered only with a Dx of breast cancer.

2.    Effective 01/01/2020: Code update – deleted code 19304 eff 01/01/2020.

3.    Updated: Revised code 19318 (eff 01-01-2021).


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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