CurrentUnitedHealthcarePolicy CS051NJ.M

Gynecomastia Surgery (for New Jersey Only)

UnitedHealthcare Community Plan medical policy applicable only to New Jersey governing when mastectomy to treat gynecomastia in males is considered reconstructive and medically necessary, with clinical criteria, definitions, applicable CPT code, and supporting evidence references.

Policy Summary

PayerUnitedHealthcare

PolicyGynecomastia Surgery (for New Jersey Only)

Policy CodePolicy CS051NJ.M

Change TypeRevised coverage criteria; updated lab examples; evidence updates

Effective DateSep 1, 2025

Next Review Date

Key ActionDocument ASPS/clinical grade (II, III, IV), presence of moderate to severe chest pain causing Functional or Physical Impairment, differentiation of glandular vs fatty tissue, trial of cessation of causative agents, and supporting laboratory testing results as applicable; follow UnitedHealthcare prior authorization processes as applicable.

POLICY UPDATE CHANGES

Replaced policy language to state 'a mastectomy to treat Gynecomastia in a male is considered reconstructive and medically necessary when all of the [listed] criteria are met'.

Revised coverage criteria wording related to 'appropriate evaluation of medical causes' and softened mandatory lab-performance language to 'supporting laboratory testing may include but is not limited to' listed tests.

Removed reference link to the Medical Policy titled Panniculectomy and Body Contouring Procedures (for New Jersey Only).

Updated Clinical Evidence and References sections to reflect current literature through 2024/2025.

1CPT code listed

3Required core criteria (age groups)

>= IIMinimum gynecomastia grade for coverage

Coverage Summary

UnitedHealthcare Community Plan medical policy (Policy Number: CS051NJ.M) effective September 1, 2025 (last reviewed September 1, 2025) addresses when mastectomy for gynecomastia in males is considered reconstructive and medically necessary in New Jersey. Coverage stance: covered_with_criteria. Status: CURRENT. Applicable population: New Jersey males. Mastectomy to treat Gynecomastia in a male is considered reconstructive and medically necessary when all listed criteria are met.

Display threshold and quick facts

Duration of Gynecomastia (pediatric)>= 2 years

Minimum gynecomastia grade for coverage>= II

CPT code listed1

Required core criteria (age groups)3

Medical Necessity Criteria

Mastectomy to treat Gynecomastia in males under age 18 - Medically Necessary

Covered when ALL of the following are met:

ALL of the following

Gynecomastia stage II, III, or IV with moderate to severe chest pain causing a Functional or Physical Impairment (the inability to participate in athletic events, sports, or social activities is not considered to be a Functional or Physical or physiological Impairment)
Glandular breast tissue is the primary cause of Gynecomastia as opposed to fatty deposits (pseudogynecomastia) and is documented on physical exam and/or mammography
Persistent Gynecomastia after cessation of prescribed medications, nutritional supplements, and appropriate screening(s) of non-prescription and/or recreational drugs or substances known to cause Gynecomastia (examples include but are not limited to testosterone, marijuana, asthma drugs, phenothiazines, anabolic steroids, cimetidine, and calcium channel blockers)
Gynecomastia must be present for at least two years

Coding

Applicable CPT CodesCPT

19300

Mastectomy for gynecomastia

Provider Actions / Prior Authorization

Prior Authorization

Prior authorization requirement implied

Mastectomy for gynecomastia is a reconstructive service considered medically necessary only when criteria are met; providers should follow UnitedHealthcare prior authorization processes as applicable in the member's plan and state contract.

19300

Documentation Required

Document gynecomastia stage and symptoms

Document ASPS/clinical grade (II, III, IV), presence of moderate to severe chest pain causing Functional or Physical Impairment, and differentiation of glandular vs fatty tissue on physical exam and/or mammography.

19300

Background, Evidence, and Definitions

Gynecomastia is benign proliferation of glandular breast tissue in males. Treatment options include discontinuation of contributing medications, medical therapy for select patients (for example, estrogen receptor modulators), and surgical options such as mastectomy with or without liposuction; choice of approach depends on gynecomastia grade, tissue type (glandular vs. fatty), and patient factors. Mastectomy can be performed via open or minimally endoscopic techniques and severe cases may require larger incisions.

Term	Definition
Gynecomastia	Breast enlargement in boys or men due to a benign (non-cancerous) increase in breast tissue (Endocrine Society, 2022).
ASPS Gynecomastia scale Grade II	Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest.
ASPS Gynecomastia scale Grade III	Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present.
ASPS Gynecomastia scale Grade IV	Marked breast enlargement with skin redundancy and feminization of the breast.
Functional or Physical Impairment	A deviation from normal function of a tissue or organ resulting in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities; inability to participate in sports or social activities alone is not sufficient.

Hayes Evidence Analysis (2024): identified 8 abstracts (single-arm studies); no clear strong support for mastectomy from guidelines. Systematic reviews / meta-analyses: Prasetyono 2022 (systematic review of surgical approaches, 18 studies, liposuction techniques, variable complication and reoperation rates), Innocenti 2022 (systematic review of complications across aspiration, excision, and combined techniques; combined techniques associated with lower complication rates than excision alone), Trinchieri 2021 (systematic review and meta-analysis of drug-induced gynecomastia showing associations for several drug classes).

Revision History

2025-09-01revisedLatest

Coverage Rationale language reworded: replaced wording 'a mastectomy for treating Gynecomastia on a male member is considered reconstructive and medically necessary when all the [listed] criteria are met' with 'a mastectomy to treat Gynecomastia in a male is considered reconstructive and medically necessary when all of the [listed] criteria are met'.

2025-09-01revisedLatest

Revised requirement for evaluation of medical causes and supporting laboratory testing: softened mandatory lab-performance phrasing to 'supporting laboratory testing may include but is not limited to' and updated examples of hormone testing.

Policy Summary

PayerUnitedHealthcare

PolicyGynecomastia Surgery (for New Jersey Only)

Policy CodePolicy CS051NJ.M

Change TypeRevised coverage criteria; updated lab examples; evidence updates

Effective DateSep 1, 2025

Next Review Date

On This Page

An appropriate evaluation of medical causes when supporting laboratory testing has been normal; supporting laboratory testing may include but is not limited to hormone testing (e.g., beta-human chorionic gonadotropin, thyroid function studies, sex-hormone binding globulin, estradiol, follicle-stimulating hormone, luteinizing hormone, prolactin, testosterone), liver enzymes, serum creatinine, and alpha-fetal protein

Supporting laboratory testing may include but is not limited to the listed tests

Mastectomy to treat Gynecomastia in males age 18 and over - Medically Necessary

Covered when ALL of the following are met:

ALL of the following

Gynecomastia stage II, III, or IV with moderate to severe chest pain causing a Functional or Physical Impairment (the inability to participate in athletic events, sports, or social activities is not considered to be a Functional or Physical or physiological Impairment)
Glandular breast tissue is the primary cause of Gynecomastia as opposed to fatty deposits (pseudogynecomastia) and is documented on physical exam and/or mammography
Persistent Gynecomastia after cessation of prescribed medications, nutritional supplements, and appropriate screening(s) of non-prescription and/or recreational drugs or substances known to cause Gynecomastia (examples include but are not limited to testosterone, marijuana, asthma drugs, phenothiazines, anabolic steroids, cimetidine, and calcium channel blockers)
An appropriate evaluation of medical causes when supporting laboratory testing has been normal; supporting laboratory testing may include but is not limited to hormone testing (e.g., beta-human chorionic gonadotropin, thyroid function studies, sex hormone binding globulin, estradiol, follicle-stimulating hormone, luteinizing hormone, prolactin, testosterone), liver enzymes, serum creatinine, and alpha-fetal protein
Supporting laboratory testing may include but is not limited to the listed tests
Note: Regardless of age, if a tumor or neoplasm is suspected, a breast ultrasound and/or mammogram may be performed with further management as indicated.

Documentation Required

Document persistence after cessation of causative agents

Document trial of cessation of prescribed medications, supplements, and appropriate screening for non-prescription and recreational substances known to cause gynecomastia and continued persistence.

Documentation Required

Document diagnostic evaluation and labs

Document appropriate evaluation of medical causes with supporting laboratory testing results noted as normal; supporting laboratory testing may include but is not limited to the listed tests.

beta-human chorionic gonadotropin (beta-hCG)
Thyroid function studies
Sex-hormone binding globulin (SHBG)
Estradiol
Follicle-stimulating hormone (FSH)
Luteinizing hormone (LH)
Prolactin
Testosterone
Liver enzymes
Serum creatinine
Alpha-fetal protein (AFP)

2025-09-01revisedLatest

Updated examples of supporting laboratory tests: added 'thyroid function studies' and 'sex-hormone binding globulin' to hormone testing examples, added 'alpha-fetal protein', and removed a prior duplicate mention of 'thyroid function studies'.

2025-09-01removedLatest

Removed reference link to the Medical Policy titled 'Panniculectomy and Body Contouring Procedures (for New Jersey Only)'.

2025-09-01revisedLatest

Clinical Evidence and References sections updated to reflect current literature through 2024/2025 (Hayes Evidence Analysis 2024 and multiple systematic reviews/meta-analyses added/updated).

2025-09-01administrativeLatest

Policy effective date set to September 1, 2025; last review recorded as September 1, 2025.