CurrentKaiser PermanentePolicy N/A

Kaiser Permanente Clinical Review Criteria for Mastectomy for Gynecomastia

Clinical review criteria governing medical necessity determinations for mastectomy to treat gynecomastia for Kaiser Foundation Health Plan of Washington members; includes documentation requirements, reference to MCG guideline KP-0273 v2 (eff 04.01.2022), and applicable CPT code 19300. Applies differently for Medicare vs non-Medicare members as noted.

Policy Summary

PayerKaiser Permanente

PolicyKaiser Permanente Clinical Review Criteria for Mastectomy for Gynecomastia

Policy CodePolicy N/A

Change TypeEndorse credentialing preferenceprior LCD/LCA additionshybrid criteria modification

Effective Date

Next Review Date

Key ActionProviders must submit the last 6 months of clinical notes from the primary care provider or specialist addressing the indications described in the medical necessity criteria to support medical necessity determination.

SourceLink

POLICY UPDATE CHANGES

Added Plastic Surgery_LCD L37020 (12/19/2017).

Added Medicare LCA A57222 (08/04/2020).

MPC approved modifications to the hybrid criteria for non-Medicare members; effective 04/01/2022 with 60-day notice (11/02/2021).

MPC approved to endorse credentialing preferences for Mastectomy (02/04/2025).

1Covered CPT code

MCG KP-0273 v2Referenced guideline

6 monthsRequired documentation period

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Coverage Summary

Clinical review criteria governing medical necessity determinations for mastectomy to treat gynecomastia for Kaiser Foundation Health Plan of Washington members; includes documentation requirements, reference to the MCG guideline KP-0273 v2 (effective 04.01.2022), and applicable CPT code 19300. Applies differently for Medicare vs non-Medicare members as noted; policy status: covered_with_criteria.

Surface key facts

Referenced guidelineMCG KP-0273 v2

Required documentation period6 months

Covered CPT code19300

Medical Necessity Criteria

Medical Necessity for Mastectomy for Gynecomastia (Non-Medicare Members)

Surgery may be medically necessary when the following criteria are met (per MCG Mastectomy for Gynecomastia KP-0273 v2 eff 04.01.2022):

ALL of the following

Presence of gynecomastia (unilateral or bilateral enlargement of the male breast due to benign proliferation of glandular elements)
Documentation of clinical evaluation and indications consistent with MCG guideline criteria
Kaiser Permanente uses the MCG guideline for determinations; specific MCG criteria are proprietary and must be accessed via provider portal or requested for individual case review
ALL of the following
- Last 6 months of clinical notes from primary care provider or specialist addressing the indications described in the medical necessity criteria

Plastic surgery credentials are preferred for mammoplasty to treat gynecomastia

Credentialing preference endorsed by MPC (02/04/2025)

Coding

Applicable CPT codesCPTCovered

19300

Mastectomy for gynecomastia

Provider Actions

Documentation Required

Submit supporting clinical documentation

Providers must submit the last 6 months of clinical notes from the primary care provider or specialist addressing the indications described in the medical necessity criteria to support medical necessity determination.

19300

Prior Authorization

MCG guideline referenced for utilization management

Kaiser Permanente uses the MCG Mastectomy for Gynecomastia (KP-0273 v2 eff 04.01.2022) guideline for medical necessity determinations; providers may request the specific criteria used for an individual case by calling Kaiser Permanente Clinical Review staff at 1-800-289-1363.

Documentation Required

Credentialing preference noted

Background

Gynecomastia is enlargement of the male breast due to benign glandular proliferation. Pubertal gynecomastia often resolves without intervention; in post-pubertal males causes include persistent pubertal gynecomastia, medications, liver disease, kidney disease, testicular tumors, or endocrine disorders. The cause is undetermined in about 25% of cases. Male breast cancer is uncommon and usually presents as a discrete breast mass.

Gynecomastia: Unilateral or bilateral enlargement of the male breast due to benign proliferation of glandular elements.

Medicare Determinations

Name	Number	Type	Effective Date
Plastic Surgery	L37020	LCD
Billing and Coding: Plastic Surgery	A57222	LCA

Revision History

12/19/2017added

Added Plastic Surgery LCD L37020.

08/04/2020added

Added Medicare LCA A57222.

11/02/2021revisedLatest

MPC approved modifications to the hybrid criteria for non-Medicare members; requires 60-day notice, effective 04/01/2022.