Gynecomastia Surgery (for Idaho Only)
Customize your policy alerts
Sign up for UnitedHealthcare Policy CS051ID.D alerts
Get alerted when Policy CS051ID.D changes without checking for updates manually.
Monitor payer policy activity
Policy governing coverage of mastectomy to treat gynecomastia for UnitedHealthcare Community Plan members in Idaho (including Idaho Medicaid Plus). Applies to providers requesting coverage for surgical treatment of gynecomastia in males.
Added instruction to refer to the Idaho Medicaid Provider Handbook, General Information and Requirements for Providers: Non-Covered and Excluded Services for additional information on non-covered and excluded services.
Removed reference link to the Medical Policy titled Panniculectomy Surgery (for Idaho Only).
Updated Clinical Evidence and References sections to reflect the most current information.
Archived previous policy version CS051ID.C.
Coverage Criteria
Medical necessity criteria
A mastectomy to treat gynecomastia in males aged 18 and over is considered reconstructive and medically necessary when ALL of the following are met:
Main coverage criteria
- AND evidence of functional impairment: Moderate to severe chest pain causing a Functional or Physical Impairment (note: inability to participate in athletic events, sports, or social activities alone is not considered a Functional or Physical Impairment).
Documentation must show cessation and appropriate screening were performed.
If tumor or neoplasm is suspected regardless of age, perform breast ultrasound and/or mammogram with further management as indicated.
For coverage determinations, the policy specifies that the inability to participate in athletic events, sports, or social activities alone is not sufficient to meet the definition of a Functional or Physical Impairment. A qualifying impairment must demonstrate a deviation from normal tissue or organ function that produces a significant limitation in movement, coordination, or performance of physical tasks as described in the policy definitions.
Providers should consult the Idaho Medicaid Provider Handbook: General Information and Requirements for Providers — Non-Covered and Excluded Services for additional detail on services that are excluded or not covered under Idaho Medicaid. Verify any state-specific exclusions or contractual terms in the handbook before submitting authorization requests or relying on this policy for coverage decisions.
Coding
| 19300 | Mastectomy for gynecomastia |
Provider Actions and Requirements
Prior authorization required for CPT 19300
Prior authorization is implied for mastectomy for gynecomastia (CPT 19300) when requesting coverage; authorization requests must demonstrate that the policy’s clinical criteria for medical necessity are met.
- Applicable procedure code: 19300 (Mastectomy for gynecomastia).
- Requests must show all required clinical criteria (see Coverage Rationale).
Verify benefit‑specific prior authorization and criteria
Before relying on this policy for coverage decisions, verify the member’s federal, state, or contractual benefit plan coverage and any benefit-specific prior authorization requirements; UnitedHealthcare may also use third‑party tools (e.g., InterQual) to assist in administering benefits.
- Check plan-specific terms because federal, state, or contractual requirements may differ from this standard policy.
Document conservative evaluation before surgery
Complete and document conservative evaluation and management before considering surgery, including cessation of contributing medications/substances, treatment of any underlying disease, and appropriate trials of medical therapy as applicable.
- Document discontinuation of prescribed medications, supplements, and screening for non‑prescription/recreational substances that can cause gynecomastia (examples listed in policy).
- Document treatment of underlying conditions and any medical therapy trials; surgery is for persistent gynecomastia after conservative measures.
No step therapy requirements specified
This policy does not specify any step therapy requirements for gynecomastia surgery in the portion provided.
- Providers should still verify any plan‑specific utilization management rules when submitting prior authorization requests.
Medical record documentation requirements
The patient’s medical record must fully document relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures to support medical necessity; records must be legible, maintained in the record, and available upon request.
- Include documentation that glandular tissue predominance, gynecomastia stage (II–IV), persistence after cessation of causative agents, and supporting laboratory/test results meet policy criteria.
- Maintain and provide records on request to support coverage determinations.
Check benefit plan requirements
Check the member’s federal, state, or contractual benefit plan coverage terms before applying this policy; providers may need to supply documentation demonstrating that plan‑specific coverage criteria are met.
- Benefit plan terms govern and may modify coverage compared with this standard policy.
- Provide any documentation requested by the plan to support coverage decisions.
Idaho Medicaid handbook reference for non‑covered/excluded services
Refer to the Idaho Medicaid Provider Handbook, General Information and Requirements for Providers: Non‑Covered and Excluded Services for additional information on non‑covered and excluded services relevant to Idaho members.
- This policy was updated to add this instruction in the Policy History/Revision Information.
Documentation and criteria deficiencies may trigger denial
Lack of documentation supporting medical necessity (history, exam, diagnostic test results) or failure to meet the policy’s specified clinical criteria (e.g., gynecomastia stage, glandular predominance, persistence after cessation of causative agents, appropriate laboratory evaluation) may result in denial of coverage.
- Ensure documentation shows all required criteria are met and supporting labs/imaging are normal or appropriately evaluated.
Benefit plan requirements govern coverage decisions
When coverage decisions conflict with this standard policy, federal, state, or contractual benefit plan requirements govern and may supersede policy guidance.
- Failure to follow applicable benefit terms may lead to denial; always confirm plan‑specific rules.
Background
Gynecomastia is a benign proliferation of glandular breast tissue in males that may be physiological or secondary to medications, systemic disease, or tumors. Management begins with identification and cessation of causative agents and evaluation for underlying medical causes; laboratory testing (for example, beta-hCG, thyroid function, sex hormone binding globulin, estradiol, FSH, LH, prolactin, testosterone, liver enzymes, serum creatinine, and alpha-fetoprotein) is recommended when indicated. Surgical treatment (mastectomy, CPT 19300) is considered reconstructive and medically necessary in males aged 18 and over when criteria are met, including ASPS Grade II, III, or IV gynecomastia with glandular predominance and persistence after appropriate conservative measures; if a tumor is suspected, breast ultrasound and/or mammography should be performed with further management as indicated.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.