ModifiedUnitedHealthcarePolicy CS051NM.C

Gynecomastia Surgery (for New Mexico Only)

Defines medical necessity criteria and coverage stance for mastectomy to treat gynecomastia for UnitedHealthcare members in New Mexico.

Policy Summary

PayerUnitedHealthcare

PolicyGynecomastia Surgery (for New Mexico Only)

Policy CodePolicy CS051NM.C

Change TypeLanguage and lab-example revisions

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization for CPT 19300 with documentation showing all listed medical necessity criteria are met.

SourceLink

POLICY UPDATE CHANGES

Replaced language clarifying that a mastectomy to treat gynecomastia in a male is considered reconstructive and medically necessary when all listed criteria are met.

Revised requirement about evaluation of medical causes and supporting laboratory testing to make lab testing optional phrasing ('may include') rather than mandatory list.

Updated list of supporting laboratory tests: added thyroid function studies and sex-hormone binding globulin to hormone testing examples, added alpha-fetoprotein, and removed duplicate mention of thyroid function studies.

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

19300Procedure code

>=2 yrsPediatric duration

ASPS II–IV

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Alpha‑FP addedLab list updated

Coverage Criteria for Mastectomy to Treat Gynecomastia

Mastectomy for gynecomastia — males under age 18 (medically necessary)

Covered when ALL of the following are met:

Pediatric criteria: 1) 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 alone does not qualify).

Pediatric criteria: 2) Glandular breast tissue is the primary cause (not pseudogynecomastia) and is documented on physical exam and/or mammography.

Pediatric criteria: 3) Persistent gynecomastia after cessation of prescribed medications, nutritional supplements, and appropriate screening of non-prescription and recreational substances known to cause gynecomastia (examples include but are not limited to testosterone, marijuana, asthma drugs, phenothiazines, anabolic steroids, cimetidine, and calcium channel blockers).

Pediatric criteria: 4) Gynecomastia present for at least two years.>= 2 years

Pediatric criteria: 5) 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-hCG, thyroid function studies, sex‑hormone binding globulin, estradiol, FSH, LH, prolactin, testosterone), liver enzymes, serum creatinine, and alpha‑fetal protein.

Mastectomy for gynecomastia — males aged 18 and over (medically necessary)

Covered when ALL of the following are met:

Adult criteria: 1) 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 alone does not qualify).

Adult criteria: 2) Glandular breast tissue is the primary cause (not pseudogynecomastia) and is documented on physical exam and/or mammography.

Adult criteria: 3) Persistent gynecomastia after cessation of prescribed medications, nutritional supplements, and appropriate screening of non-prescription and recreational substances with known association with gynecomastia (examples include but are not limited to testosterone, marijuana, asthma drugs, phenothiazines, anabolic steroids, cimetidine, and calcium channel blockers).

Adult criteria: 4) 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‑hCG, thyroid function studies, sex‑hormone binding globulin, estradiol, FSH, LH, prolactin, testosterone), liver enzymes, serum creatinine, and alpha‑fetal protein.

ASPS surgical candidacy criteria (informing coverage)

ASPS recommendations cited for surgical candidacy by grade, duration, and prior therapy:

Adolescents - ASPS 2016: Unilateral or bilateral grade II or III gynecomastia present (per modified McKinney and Simon, Hoffman, and Kohn scales) that continues more than one year after pathological causes are ruled out, or that continues after six months of failed medical treatment; OR unilateral or bilateral grade IV gynecomastia that continues more than six months after pathological causes are ruled out or after six months of failed medical treatment.time thresholds: >6 months to >1 year depending on grade

From ASPS 2016 recommendations

Adults - ASPS 2016: Unilateral or bilateral grade III or IV gynecomastia present; persists for more than 3 to 4 months after pathological causes are ruled out or after 3 to 4 months of failed medical therapy. Breast biopsy is suggested when malignancy is presumed.3 to 4 months

From ASPS 2016 recommendations

Exclusions include pseudogynecomastia (fatty enlargement) when glandular breast tissue is not the primary cause; such cases are not considered reconstructive for coverage. The policy also excludes situations where the member cannot demonstrate the required elements of the criteria (for example, insufficient documentation that glandular tissue is primary, inadequate duration, or lack of documented Functional or Physical Impairment). Operatively, if pathology and imaging/physical exam do not show predominant glandular tissue, surgical removal for primarily fatty enlargement would not meet reconstructive coverage and may be denied.

Note: this information is provided for context only. Surgical procedures, including mastectomy for gynecomastia, are not regulated by the U.S. Food and Drug Administration for the purposes of coverage determination; FDA approval alone is not a basis for coverage.

Examples of cases that do not meet ALL specified criteria and therefore are considered not medically necessary include: lower-grade gynecomastia (e.g., Grade I) or enlargement that is primarily fatty (pseudogynecomastia); gynecomastia present for less than the required duration (for pediatric criteria, less than 2 years); absence of documented glandular tissue on physical exam or imaging; failure to show persistent condition after cessation of causative medications/supplements/substances; and lack of documentation of an appropriate evaluation of medical causes (including supporting laboratory testing when performed).

Procedures that do not meet all listed reconstructive or medical necessity criteria are not covered as reconstructive/medically necessary. Coverage is contingent on meeting every criterion in the policy; prior authorization and submitted clinical documentation must demonstrate that all criteria are satisfied to support payment as reconstructive treatment.

Coding and Procedure Codes

Referenced CPT CodesCPT

19300

Mastectomy for gynecomastia

Minimum duration (pediatric)

Duration>= 2 years

Applies toMales under age 18 (pediatric criteria)

ContextRequired persistence after cessation of causative medications/supplements and screening of recreational substances

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for CPT 19300 (Mastectomy for gynecomastia). Approvals must document that the member meets all policy criteria below; lack of prior authorization or insufficient documentation may result in denial.

Affected code: CPT 19300
Ensure prior authorization approval notes that member meets all policy criteria

Documentation Required

Document Gynecomastia Stage (ASPS/Grade)

Document the gynecomastia grade/stage using the American Society of Plastic Surgeons (ASPS) or referenced grading scales (e.g., modified McKinney and Simon, Hoffman, and Kohn). For adolescents, ASPS guidance identifies Grade II, III (and IV) thresholds; for adults, Grade III or IV is relevant. Explicitly record the grade/scale used and clinical findings that support the grade.

Record ASPS grade (II, III, or IV) or alternative referenced scale and findings

Background and Scope

Gynecomastia is a benign proliferation of glandular breast tissue in males and may be physiologic (for example, neonatal, pubertal, or age-related) or secondary to medical conditions, medications, supplements, recreational substances, or tumors. Common secondary causes include drugs with known associations (examples listed in the coverage criteria include testosterone, marijuana, certain asthma medications, phenothiazines, anabolic steroids, cimetidine, and calcium channel blockers) and endocrine or systemic disorders. Clinical management begins with identifying and discontinuing contributing agents when possible, appropriate laboratory or imaging evaluation to exclude pathologic causes, consideration of medical therapy in select cases, and surgical removal (mastectomy) when gynecomastia is persistent and meets severity and functional-impairment thresholds per the policy and referenced ASPS guidance.

Definitions and Grading

Gynecomastia (definition)

DefinitionBreast enlargement in boys or men due to a benign (non-cancerous) increase in breast tissue (Endocrine Society, 2022).

ContrastDistinct from pseudogynecomastia, which is fatty enlargement where glandular tissue is not primary.

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.

Revision History and Policy Changes

2025-08-01policy_revisionLatest

Replaced wording to clarify 'a mastectomy to treat Gynecomastia in a male' and updated coverage rationale language to require that all listed criteria be met.

2025-08-01criteria_revision

Revised evaluation of medical causes language to make supporting laboratory testing optional phrasing ('may include') rather than mandatory and updated the list of supporting laboratory tests.

2025-08-01

Policy Summary

PayerUnitedHealthcare

PolicyGynecomastia Surgery (for New Mexico Only)

Policy CodePolicy CS051NM.C

Change TypeLanguage and lab-example revisions

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization for CPT 19300 with documentation showing all listed medical necessity criteria are met.

SourceLink

On This Page

Adult criteria: Note: Regardless of age, if tumor or neoplasm is suspected, a breast ultrasound and/or mammogram may be performed with further management as indicated.

State which scale was used (ASPS, McKinney and Simon, Hoffman, Kohn)

Documentation Required

Conservative Measures and Evaluation of Underlying Causes

Providers must evaluate and document conservative measures and assessment of underlying causes prior to surgical consideration. This includes cessation of any prescribed medications, supplements, or recreational substances known to cause gynecomastia, and appropriate evaluation for medical causes with supporting laboratory testing when indicated.

Document cessation of causative drugs/substances (e.g., testosterone, marijuana, anabolic steroids, cimetidine, calcium channel blockers, select asthma drugs, phenothiazines)
Document clinical evaluation for underlying pathology and any interventions performed
Include results of relevant imaging when tumor/neoplasm suspected (breast ultrasound and/or mammogram)

Documentation Required

Prior Medical Therapy Documentation

Prior medical therapy must be documented per ASPS guidance: duration and response to medical treatment (e.g., failed medical therapy for stated timeframes). For adolescents, document persistence >1 year after pathological causes ruled out or >6 months after failed medical treatment for certain grades; for adults, document persistence for 3–4 months after pathological causes ruled out and after 3–4 months of failed medical therapy as applicable. Include detail on specific therapies tried, start/stop dates, and reasons for discontinuation.

List prior medical therapies tried (medication names, doses, dates)
Document duration of therapy and clinical response or failure
For adolescents: note >1 year persistence OR >6 months after failed medical treatment when applicable; Grade IV may require >6 months persistence
For adults: document persistence and failed medical therapy for 3–4 months as applicable

Documentation Required

Documentation Checklist

Documentation checklist — provide clear documentation of gynecomastia stage/grade, physical exam and/or mammography confirming glandular tissue as the primary cause (exclude pseudogynecomastia), duration of condition, cessation of causative agents, details of prior medical therapies and durations, and relevant laboratory or imaging results. Absent or insufficient documentation (e.g., stage I disease, pseudogynecomastia, inadequate duration, or no prior therapy when required) increases risk of denial.

Gynecomastia grade/stage with scale referenced
Physical exam and/or mammography documenting glandular tissue
Duration of gynecomastia (e.g., >= 2 years where required, or ASPS-specific durations)
Cessation of causative medications/substances and documentation of watchful waiting
Prior medical therapies with dates and documented failure/response
Supporting laboratory testing results when performed (hormone tests, liver enzymes, serum creatinine, AFP, etc.)

Denial Risk

Procedure may be denied if all policy criteria are not met. Common reasons for denial include: gynecomastia limited to Stage I, predominance of fatty tissue (pseudogynecomastia) rather than glandular tissue, insufficient documented duration, lack of documentation of prior medical therapy or failure when required, missing evidence of cessation of causative agents, or absence of required prior authorization.

Denial risk: Stage I gynecomastia
Denial risk: pseudogynecomastia (fatty tissue primary)
Denial risk: insufficient duration documented
Denial risk: no documentation of prior medical therapy or failure when required
Denial risk: no prior authorization or insufficient approval documentation

Prior Authorization

Prior Authorization Submission Requirements

Submit supporting clinical documentation with prior authorization requests per policy requirements. Include operative indication tied to policy criteria, imaging and lab results, documentation of conservative measures and medication cessation, and evidence of prior medical therapy and duration. Coverage is contingent on meeting all listed criteria; if reconstructive/medical necessity criteria are not fully met, the service may not be covered.

Attach physical exam notes and imaging (mammogram/ultrasound) showing glandular tissue
Include laboratory results and list of prior therapies with dates
Provide documentation of prior authorization approval referencing member meets policy criteria

Functional or Physical Impairment (definition)

DefinitionA deviation from normal tissue or organ function resulting in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities (difficulties with physical/motor tasks, independent movement, or basic life functions).

Exclusion noteInability to participate in athletic events, sports, or social activities alone does not qualify as a Functional or Physical Impairment for coverage.

Clinical implicationModerate to severe chest pain causing such impairment is required for coverage eligibility.

Gynecomastia grade (ASPS / referenced scales)

Referenced scalesModified McKinney and Simon, Hoffman, and Kohn scales (used by ASPS for grading).

ASPS adolescent thresholdsGrade II or III: persistent >1 year after pathological causes ruled out (or >6 months after failed medical treatment); Grade IV: persists >6 months after pathological causes ruled out or failed medical treatment.

ASPS adult thresholdsGrade III or IV: persists 3–4 months after pathological causes ruled out or after 3–4 months of failed medical therapy; consider breast biopsy when malignancy is presumed.

Updated examples of hormone testing to add thyroid function studies and sex-hormone binding globulin, added alpha-fetoprotein, and removed a duplicate mention of thyroid function studies.

2025-08-01removed_reference

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

2025-08-01supporting_info_updated

Updated Clinical Evidence and References sections and archived previous policy version CS051NM.B.