ModifiedUnitedHealthcarePolicy CSOS1LAM

Gynecomastia Surgery (for Louisiana Only)

Medical policy governing when mastectomy for gynecomastia is considered reconstructive and medically necessary for members in Louisiana; covers diagnostic evaluation, criteria, and applicable procedure coding.

Policy Summary

PayerUnitedHealthcare

PolicyGynecomastia Surgery (for Louisiana Only)

Policy CodePolicy CSOS1LAM

Change TypeRevised coverage language and lab testing examples

Effective DateSep 1, 2025

Next Review Date

Key ActionSubmit prior authorization for CPT 19300 with documentation of glandular breast tissue, stage II–IV impairment, duration (>=2 years), and evaluation/laboratory results.

SourceLink

POLICY UPDATE CHANGES

Replaced wording describing when a mastectomy to treat gynecomastia is considered reconstructive and medically necessary to use 'a mastectomy to treat Gynecomastia in a male is considered reconstructive and medically necessary when all of the [listed] criteria are met.'

Replaced requirement phrasing about evaluation of medical causes and supporting laboratory testing to make testing optional examples: 'an appropriate evaluation of medical causes when supporting laboratory testing has been normal; supporting laboratory testing may include but is not limited to the [listed tests].'

Updated list of supporting laboratory tests: added thyroid function studies, sex-hormone binding globulin, added alpha-fetoprotein, and removed an earlier duplicate item 'thyroid function studies'.

Archived previous policy version CSOS1LAL.

LAPolicy application state

>=2yMinimum duration

II–IV

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1Archived prior version

Coverage Criteria for Mastectomy to Treat Gynecomastia

Mastectomy for gynecomastia — patients <18

Covered when ALL of the following are met

Under 18 coverage criteria: Patient is male under age 18; glandular breast tissue is the primary cause of gynecomastia (documented by physical exam and/or mammography); gynecomastia is stage II, III, or IV (ASPS grading) with moderate to severe chest causing a Functional or Physical Impairment (social/athletic inability alone is not considered a Functional or Physical Impairment); gynecomastia persists after cessation of prescribed medications, nutritional supplements, and appropriate screening of non-prescription and/or recreational substances known to cause gynecomastia; 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 including beta-hCG, thyroid function studies, sex-hormone binding globulin, estradiol, FSH, LH, prolactin, testosterone; serum creatinine; liver enzymes; alpha-fetoprotein); and gynecomastia has been present for at least two years.duration >= 2 years

Functional or Physical Impairment definition applies

Mastectomy for gynecomastia — patients >=18

Covered when ALL of the following are met

Adult coverage criteria: Patient is male aged 18 or older; glandular breast tissue is the primary cause of gynecomastia (documented by physical exam and/or mammography); gynecomastia is stage II, III, or IV (ASPS grading) with moderate to severe chest causing a Functional or Physical Impairment (social/athletic inability alone is not considered a Functional or Physical Impairment); persistent gynecomastia after cessation of prescribed medications, nutritional supplements, and appropriate screening of non-prescription and/or recreational substances known to cause gynecomastia; 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 such as beta-hCG, thyroid function studies, sex-hormone binding globulin, estradiol, FSH, LH, prolactin, testosterone; liver enzymes; alpha-fetoprotein; serum creatinine).not specified beyond stage and persistence

If tumor or neoplasm is suspected, perform breast ultrasound and/or mammogram with further management as indicated

Covered when all listed criteria are met

Policy states a mastectomy to treat gynecomastia in a male is considered reconstructive and medically necessary when all of the listed criteria are met.

Mastectomy for gynecomastia — overall requirement: A mastectomy to treat Gynecomastia in a male is considered reconstructive and medically necessary when all of the [listed] criteria are met.

Full list of listed criteria appears in the coverage rationale sections for specified age groups and related documentation requirements within the policy.

Pseudogynecomastia (breast enlargement due primarily to fatty tissue rather than glandular proliferation) is excluded from coverage unless the medical record documents that glandular breast tissue is the primary cause. Documentation must include physical examination findings and/or mammography demonstrating glandular tissue as the dominant etiology before mastectomy for gynecomastia will be considered reconstructive and medically necessary.

FDA clearance or approval of a device or product alone does not establish coverage. Additionally, surgical procedures for the treatment of gynecomastia are procedures and are not regulated by the U.S. Food and Drug Administration; therefore FDA status is informational only and is not a basis for determining medical necessity.

Requests for mastectomy to treat gynecomastia will be denied when the condition is predominantly fatty (pseudogynecomastia) or when the clinical criteria are not met. Specifically, coverage requires documented Stage II, III, or IV gynecomastia with associated Functional or Physical Impairment, persistence after cessation of causative medications/substances, and appropriate evaluation including supporting laboratory testing when indicated. The policy also requires gynecomastia to have been present for >= 2 years (as applicable in the age-specific criteria) or otherwise meet the stated duration/persistence and evaluation requirements.

Procedure Coding and Key Values

Covered CPT Codes (reference list)CPT

19300

Mastectomy for gynecomastia

Duration of gynecomastia — required minimum

Required minimum durationGynecomastia must be present for at least two years (>= 2 years)

Documentation of persistencePersistence after cessation of prescribed medications, supplements, and screening of non-prescription/recreational drugs must be demonstrated

Applies toSpecified in coverage criteria for males both under 18 and aged 18 and over as a continuity requirement

Provider Actions, Authorization, and Documentation Requirements

Note

Confirm benefit plan and potential external criteria

Confirm the member's benefit plan and check for any federal, state, or contractual requirements that may govern coverage decisions. In the event of a conflict between this Medical Policy and the member's plan terms or applicable law, the federal, state, or contractual requirements govern. UnitedHealthcare may also apply third-party criteria (for example, InterQual) when administering benefits; verify whether such external criteria apply to the case.

Verify member's benefit plan and any applicable federal/state/contractual mandates
Confirm whether external criteria (e.g., InterQual) will be used in benefit determination
When conflicts exist, plan/federal/state/contract terms govern coverage

Prior Authorization

Prior Authorization / Authorization Note

Prior authorization is implied when medical necessity criteria for CPT 19300 (mastectomy for gynecomastia) are met; submit required clinical documentation to support medical necessity decisions.

Affected code: CPT 19300 — Mastectomy for gynecomastia

Background and Context

Gynecomastia is a benign proliferation of breast tissue in males that may be physiologic or secondary to medical conditions, medications, supplements, recreational substances, or tumors. Standard evaluation includes identifying and discontinuing potential causative agents and assessing for medical causes with appropriate laboratory testing (examples include hormone testing, liver enzymes, serum creatinine, and alpha‑fetoprotein). Surgical management (mastectomy, often with liposuction) is reserved for persistent or severe cases—coverage criteria require documented glandular predominance, graded severity (Stage II–IV), persistence after conservative measures, and appropriate diagnostic evaluation. Note that surgical procedures for gynecomastia are not regulated by the FDA; FDA status is informational only.

Definitions and Grading

Gynecomastia — definition

DefinitionGynecomastia is breast enlargement in boys or men due to a benign (non-cancerous) increase in breast tissue.

Age groupsDefinition applies to males of all ages; separate coverage criteria exist for <18 and >=18

Source guidanceReferenced to Endocrine Society (2022) in policy definitions

Functional or Physical Impairment — definition

DefinitionFunctional or Physical Impairment: deviation from normal tissue or organ function causing significantly limited capacity to move, coordinate actions, or perform physical activities and basic life functions.

Clinical impactMay include difficulty with physical/motor tasks, independent movement, or performing basic life functions

Policy Revision History and Changes

2025-09-01Material revisionLatest

Revised coverage rationale and criteria wording for mastectomy to treat gynecomastia, clarified evaluation/laboratory testing phrasing, updated examples of supporting laboratory tests (added thyroid function studies, sex‑hormone binding globulin, added alpha‑fetoprotein, removed duplicate thyroid listing).

Archival of prior version

Archived previous policy version CSOS1LAL.

Policy Summary

PayerUnitedHealthcare

PolicyGynecomastia Surgery (for Louisiana Only)

Policy CodePolicy CSOS1LAM

Change TypeRevised coverage language and lab testing examples

Effective DateSep 1, 2025

Next Review Date

Key ActionSubmit prior authorization for CPT 19300 with documentation of glandular breast tissue, stage II–IV impairment, duration (>=2 years), and evaluation/laboratory results.

SourceLink

On This Page

Submit clinical documentation that demonstrates how criteria are met (see Documentation requirements callouts)

Documentation Required

Required documentation

Required documentation must clearly demonstrate that glandular breast tissue is the primary cause of gynecomastia and must include details on stage, duration, persistence after conservative measures, and relevant exam/imaging findings.

Physical exam documentation confirming palpable glandular tissue or mammography/breast imaging if exam is equivocal
Gynecomastia grade/stage (ASPS or equivalent scale) and description of severity
Duration of gynecomastia (must be present for at least 2 years for adolescents per criteria) and documentation of persistence despite conservative measures
Record of cessation of causative medications/supplements and screening for nonprescription/recreational substances
Clinical notes supporting functional or physical impairment (as defined) and any pain or limitation attributable to gynecomastia

Documentation Required

Evaluation and laboratory testing documentation

Document evaluation and any laboratory testing used to rule out medical causes. Include test names, dates, and results when available.

Examples of supportive laboratory testing: hormone testing (beta-hCG, estradiol, FSH, LH, prolactin, testosterone, sex-hormone binding globulin), thyroid function studies
Serum creatinine and liver enzyme testing
Alpha-fetoprotein when clinically indicated
Imaging or biopsy results if malignancy is suspected (breast ultrasound, mammogram, core needle biopsy)
Notes from specialist evaluation when a comprehensive diagnostic workup was performed

Note

Conservative management expectation

Conservative management expectations should be documented and attempted when appropriate prior to surgery. Document cessation of causative agents, treatment of underlying conditions, and any medical therapies or watchful waiting performed.

Record cessation of prescribed medications, nutritional supplements, and identified recreational/nonprescription substances known to cause gynecomastia
Document treatment of underlying pathology (e.g., endocrine disorders) and the period of watchful waiting after such treatment
Document any medical therapies tried (and response), noting that routine use of SERMs, aromatase inhibitors, or non-aromatizable androgens is generally not recommended

Note

None specified

No additional provider actions are specified in this part of the document beyond the requirements and checks noted above.

Note

Plan / contract alignment required

Coverage decisions must reference and align with the member's benefit plan terms; when plan/federal/state/contractual requirements differ from this Medical Policy, the applicable plan or legal requirements prevail.

If a conflict exists between this policy and plan-specific or legal requirements, the plan/state/federal requirement governs
Verify any contract-specific language prior to rendering a coverage determination

Denial Risk

Potential denial triggers

Potential denial triggers: lacking documentation that glandular tissue is the primary cause (versus pseudogynecomastia); missing gynecomastia stage/grade; insufficient documentation of duration and persistence after conservative measures; absent evaluation/lab testing when indicated.

No physical exam or imaging documenting glandular tissue
No recorded gynecomastia stage/grade or severity
No evidence of cessation of causative agents or attempted conservative management
Missing or incomplete evaluation/lab testing where clinically indicated

Coverage noteSocial or athletic inability alone is not considered a Functional or Physical Impairment per the policy

ASPS Gynecomastia scale (Grades II-IV)

Grade IIModerate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest.

Grade IIIModerate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present.

Grade IVMarked breast enlargement with skin redundancy and feminization of the breast.

Regulatory status — surgeries for gynecomastia

Regulatory statusSurgeries for the treatment of gynecomastia are procedures and therefore not regulated by the U.S. Food and Drug Administration.

Coverage implicationFDA approval alone is not a basis for coverage; policy uses FDA information for reference only.

ReferencePolicy directs readers to FDA resources for informational purposes (link provided in source).