CurrentUnitedHealthcarePolicy CS051TN.O

Gynecomastia Surgery (for Tennessee Only)

Defines medical necessity criteria for mastectomy to treat gynecomastia for Medicaid and CoverKids members in Tennessee, including required clinical findings, diagnostic evaluation, and duration. Also provides related CPT code and background/evidence summary.

Policy Summary

PayerUnitedHealthcare

PolicyGynecomastia Surgery (for Tennessee Only)

Policy CodePolicy CS051TN.O

Change TypeRevisions to wording and supporting lab examples

Effective DateAug 1, 2025

Next Review Date

Key ActionDocument gynecomastia grade, glandular etiology, persistence after cessation of causative agents, and supporting laboratory evaluation results; obtain prior authorization as required.

SourceLink

POLICY UPDATE CHANGES

Replaced wording to state 'a mastectomy to treat Gynecomastia in a male is considered reconstructive and medically necessary when all of the [listed] criteria are met' (from prior phrasing referencing 'on a male member').

Revised coverage criteria: modified wording for evaluation of medical causes and supporting laboratory testing to be permissive ('may include') rather than mandatory list.

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

Updated Clinical Evidence and References sections to reflect the most current information.

Revised list of supporting laboratory tests examples (added alpha-fetal protein).

1Primary CPT code listed

3Required core criteria (grade, glandular etiology, persistence)

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4Example supporting labs listed

Coverage Summary

Defines medical necessity criteria for a mastectomy to treat Gynecomastia for Medicaid and CoverKids members in Tennessee, including required clinical findings, diagnostic evaluation, and duration. Policy Number: CS051TN.O. Effective Date: August 1, 2025. Applies to male members (both pediatric and adult age groups addressed). Coverage stance: covered with criteria — a mastectomy to treat gynecomastia is considered reconstructive and medically necessary only when all specified criteria are met.

Key thresholds & quick facts

Primary CPT code listed1 (CPT 19300: Mastectomy for gynecomastia)

Required core criteria3 (Grade II–IV; glandular etiology documented; persistent after cessation of causative agents)

Example supporting labs listed4 (hormone testing including beta-hCG, thyroid function studies, SHBG, estradiol, FSH, LH, prolactin, testosterone; liver enzymes; serum creatinine; alpha-fetal protein)

Duration threshold>= 2 years (for males under 18)

Medical Necessity Criteria

Mastectomy to treat Gynecomastia (male under 18)

A mastectomy to treat Gynecomastia in a male under the age of 18 is considered reconstructive and medically necessary when ALL of the following criteria are met:

ALL of the following

Core clinical criteria
- Gynecomastia grade and symptoms: 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)
- Tissue etiology: Glandular breast tissue is the primary cause of Gynecomastia as opposed to fatty deposits (pseudogynecomastia) and is documented on physical exam and/or mammography

Coding

Applicable CPT code(s)CPT

19300

Mastectomy for gynecomastia

Provider Actions

Documentation Required

Document gynecomastia grade and impairment

Document the gynecomastia stage using the ASPS/grade scale and record that it is stage II, III, or IV with moderate to severe chest pain causing a functional or physical impairment. Note that inability to participate in sports or social activities alone does not meet the impairment requirement.

19300

Documentation Required

Document glandular tissue etiology

Document that glandular breast tissue (true gynecomastia) — not fatty pseudogynecomastia/lipomastia — is the primary cause, demonstrated on physical examination and/or mammography.

19300

Documentation Required

Document prior discontinuation of causative agents

Background & Evidence

Gynecomastia is a benign proliferation of glandular breast tissue in males, common in newborns, adolescents, and older men. Treatment begins with identifying and discontinuing causative medications, supplements, or addressing underlying chronic conditions (e.g., cirrhosis, hypogonadism, renal insufficiency). Medical therapy (such as selective estrogen receptor modulators in select patients) can be considered, but surgery has a role for persistent, symptomatic, or severe cases.

Surgical approaches include open subcutaneous mastectomy, skin-sparing mastectomy with or without liposuction, minimally endoscopic techniques, and combined techniques (mastectomy plus liposuction). Evidence is largely from single-arm studies and systematic reviews showing improvements in satisfaction and quality of life with variable complication and reoperation rates; combined techniques may reduce complications compared to excision alone.

Guideline recommendations emphasize evaluating and excluding underlying pathology (including medication or substance causes and possible tumors) before surgery. Guidelines advise confirming palpable glandular tissue (to distinguish from pseudogynecomastia), performing appropriate laboratory and imaging evaluation when indicated, and offering surgery for persistent gynecomastia that does not resolve with time or medical therapy — with timelines and grade-based recommendations varying by guideline and age.

Source	Summary
Hayes Evidence Analysis (2024)	Found eight abstracts; evidence limited to single-arm studies and no clear support for mastectomy for treatment of gynecomastia.
Prasetyono 2022 (systematic review)	Examined surgical approaches including liposuction-assisted techniques (18 studies, 244 individuals); showed consistent QoL improvements and technical advantages for small incisional liposuction, but complication and reoperation rates were heterogeneous (complications 0.06–26.67%, reoperation 0.6–25%); authors call for larger, higher-quality studies.
Innocenti 2022 (systematic review)	Analyzed 94 articles (7,294 individuals) across aspiration, excision, and combined techniques; combined techniques had lower complication rates than excision alone, but heterogeneity in classifications and methods limits conclusions.

Definitions (compact)

GynecomastiaBreast enlargement in boys or men due to a benign increase in breast tissue (Endocrine Society, 2022)

ASPS Grade II

Revision History

08/01/2025language clarification

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

08/01/2025lab list update (material)Latest

Revised coverage criteria to make supporting laboratory testing permissive ('may include' rather than mandatory) and updated examples: added 'thyroid function studies, sex-hormone binding globulin' to hormone testing examples, added 'alpha-fetal protein', and removed a prior duplicate 'thyroid function studies'.

Policy Summary

PayerUnitedHealthcare

PolicyGynecomastia Surgery (for Tennessee Only)

Policy CodePolicy CS051TN.O

Change TypeRevisions to wording and supporting lab examples

Effective DateAug 1, 2025

Next Review Date

Key ActionDocument gynecomastia grade, glandular etiology, persistence after cessation of causative agents, and supporting laboratory evaluation results; obtain prior authorization as required.

SourceLink

On This Page

Prior discontinuation of causative agents:

Persistent Gynecomastia after cessation of prescribed medications, nutritional supplements, and appropriate screening(s) of non-prescription and/or recreational drugs or substances that have a known side effect of Gynecomastia (examples include but are not limited to testosterone, marijuana, asthma drugs, phenothiazines, anabolic steroids, cimetidine, and calcium channel blockers)

Duration of gynecomastia: Gynecomastia must be present for at least two years>= 2 years

Evaluation/labs

Supporting laboratory testing examples (ONE or more may apply)
- 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
- Alpha-fetal protein

Mastectomy to treat Gynecomastia (male aged 18 and over)

A mastectomy to treat Gynecomastia in a male aged 18 and over is considered reconstructive and medically necessary when ALL of the following criteria are met:

ALL of the following

Core clinical criteria
- Gynecomastia grade and symptoms: 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)
- Tissue etiology: Glandular breast tissue is the primary cause of Gynecomastia as opposed to fatty deposits (pseudogynecomastia) and is documented on physical exam and/or mammography
- Prior discontinuation of causative agents: Persistent Gynecomastia after cessation of prescribed medications, nutritional supplements, and appropriate screening(s) of non-prescription and/or recreational drugs or substances that have a known side effect of Gynecomastia (examples include but are not limited to testosterone, marijuana, asthma drugs, phenothiazines, anabolic steroids, cimetidine, and calcium channel blockers)
- Evaluation/labs
  - Supporting laboratory testing examples (ONE or more may apply)
    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
    Alpha-fetal protein
- Tumor/neoplasm note: 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.

Document that gynecomastia has persisted after stopping prescribed medications and nutritional supplements and after appropriate screening for non-prescription or recreational drugs/substances known to cause gynecomastia.

Examples: testosterone, marijuana, asthma drugs, phenothiazines, anabolic steroids, cimetidine, calcium channel blockers
19300

Documentation Required

Laboratory evaluation documentation

Document an appropriate evaluation for medical causes and include results of supporting laboratory testing when normal. Supporting tests may include one or more hormone and related panels, liver enzymes, serum creatinine, and alpha-fetoprotein.

Possible tests (ONE or more may apply): beta-hCG; thyroid function studies; sex-hormone binding globulin (SHBG); estradiol; FSH; LH; prolactin; testosterone
Liver enzymes
Serum creatinine
Alpha-fetoprotein

Prior Authorization

Prior authorization implied by medical policy

Prior authorization should be obtained as required by the member's plan processes. This policy outlines the medical necessity criteria used to interpret coverage decisions for mastectomy to treat gynecomastia.

19300

Moderate enlargement exceeding areola boundaries with edges indistinct from chest

ASPS Grade IIIModerate enlargement exceeding areola with skin redundancy present

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

Functional or Physical ImpairmentDeviation from normal tissue/organ function causing significantly limited or impaired capacity to move or perform physical activities (Medicare, 2023)

08/01/2025link removed

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

08/01/2025evidence update

Updated Clinical Evidence and References sections to reflect the most current information, including Hayes 2024 brief and recent systematic reviews.