ModifiedUnitedHealthcarePolicy CS051TN.O

Gynecomastia Surgery (for Tennessee Only)

Medical policy governing coverage criteria for mastectomy to treat gynecomastia for Medicaid and CoverKids members in Tennessee; defines medical necessity requirements by age and clinical findings. Applies to providers requesting authorization and claims adjudication in Tennessee.

Policy Summary

PayerUnitedHealthcare

PolicyGynecomastia Surgery (for Tennessee Only)

Policy CodePolicy CS051TN.O

Change TypeRevised coverage criteria and laboratory testing guidance

Effective DateAugust 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for mastectomy (CPT 19300) and submit documentation showing all coverage criteria and supporting laboratory evaluation when applicable.

SourceLink

POLICY UPDATE CHANGES

Replaced wording to specify that a mastectomy to treat gynecomastia in a male is considered reconstructive and medically necessary when all listed criteria are met; changed required lab testing language from mandatory to permissive and updated examples of supporting laboratory tests (added thyroid function studies, sex-hormone binding globulin, and alpha-fetoprotein).

Removed a related policy link and refreshed the Clinical Evidence and References sections.

ASPS II–IVseverity grades referenced

>=2 yrsminimum duration

19300procedure code

Tennessee

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severalreferences updated

Coverage Criteria for Mastectomy to Treat Gynecomastia

Medical necessity criteria (pediatric and adult)

Covered when ALL of the following are met for mastectomy to treat gynecomastia:

Primary criteria set: 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 is not considered a Functional or Physical or physiological Impairment).

Primary criteria set: 2) Glandular breast tissue is the primary cause of gynecomastia (not pseudogynecomastia) documented on physical examination and/or mammography.

Primary criteria set: 3) Gynecomastia is persistent after cessation of prescribed medications, nutritional supplements, and appropriate screening 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).

Primary criteria set: 4) Gynecomastia has been present for at least two years.>= 2 years

Primary criteria set: 5) 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-fetoprotein.

Supporting laboratory testing is listed as examples and may be included as part of the evaluation.

Mastectomy to treat Gynecomastia — covered when ALL criteria met

Revised coverage criteria for mastectomy to treat gynecomastia in a male require that ALL of the following be met:

Mastectomy coverage criteria (summary): All listed criteria must be met for a mastectomy to be considered reconstructive and medically necessary. An appropriate evaluation of medical causes with supporting laboratory testing when normal may include specified hormone tests, sex-hormone binding globulin, and alpha-fetoprotein.

The policy specifies that an inability to participate in athletic events, sports, or social activities alone does not qualify as a Functional or Physical Impairment for coverage of mastectomy to treat gynecomastia. For coverage, the chest pain must be moderate to severe and cause a Functional or Physical Impairment beyond restriction of participation in such activities, and this impairment must be documented as part of the medical necessity assessment.

This section is informational: FDA approval alone is not a basis for coverage. The policy notes that surgeries to treat gynecomastia are procedural and are not regulated by the FDA; therefore FDA clearance or approval does not determine coverage. Providers may reference the FDA site for device or procedural information, but coverage decisions follow the policy criteria.

Procedures that do not meet the policy's explicit clinical thresholds are not covered. Examples include cases without ASPS grade II–IV severity, cases where glandular breast tissue is not the primary cause (pseudogynecomastia), gynecomastia that has not persisted despite appropriate cessation of prescribed medications and substances known to cause gynecomastia, or disease present for less than the required duration (generally at least two years where specified). Additionally, coverage requires appropriate evaluation of medical causes with normal supporting laboratory testing when performed; absence of these findings or documentation may lead to noncoverage.

The policy defines procedures as not medically necessary when the listed coverage criteria are not met. Specifically, mastectomy for gynecomastia is not considered medically necessary if the case fails to meet required severity (ASPS grade II–IV), does not demonstrate glandular tissue as the primary cause, lacks persistence after cessation of causative agents, does not meet duration requirements, or does not include appropriate evaluation and normal supporting laboratory/diagnostic testing when indicated.

Coding and Procedure Codes

Covered CPT Codes (referenced)CPTCovered

19300

Mastectomy for gynecomastia

Applicable codes (policy updated list)mixed

No codes listed

Duration of gynecomastia — threshold

Minimum durationGynecomastia must be present for at least two years (>= 2 years).

ContextApplies to mastectomy to treat gynecomastia for both pediatric (<18) and adult (≥18) criteria sets where duration is specified.

Evidence referenceStated explicitly in coverage rationale requirements for reconstructive and medically necessary mastectomy to treat gynecomastia.

Misc coding note

Coding noteNone specified in this part.

ContextPolicy revision updated Applicable Codes list; no additional coding clarifications provided in this section.

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for CPT 19300 (mastectomy for gynecomastia). Submit a prior authorization request and include complete clinical documentation demonstrating that medical necessity criteria are met.

Prior authorization required before scheduling surgery.
Include documentation that all coverage criteria in the policy are met.

Documentation Required

Documentation Required — Demonstrate All Criteria Met

Documentation must demonstrate that all listed coverage criteria are met. This includes exam findings, imaging (mammography and/or ultrasound when indicated), documentation that glandular tissue is the primary cause (not pseudogynecomastia), duration of gynecomastia, and results of any relevant laboratory testing.

Document ASPS grade (II–IV) or equivalent exam findings.
Document glandular tissue on physical exam and/or imaging.

Background and Context

Gynecomastia is a benign proliferation of glandular breast tissue in males. Causes include physiologic phases (e.g., neonatal, pubertal, and older age-related changes), medications and substances (examples listed in the policy include testosterone, marijuana, asthma medications, phenothiazines, anabolic steroids, cimetidine, and calcium channel blockers), systemic disease, and, rarely, tumors. Management includes identifying and addressing underlying causes, medical therapy in select situations, and surgical mastectomy when gynecomastia is persistent, glandular in origin, meets ASPS grade II–IV severity, and is associated with significant symptoms such as moderate to severe chest pain causing functional impairment.

Definitions and Severity Scales

Gynecomastia — definition

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

Clinical implicationDistinguishes true glandular enlargement from pseudogynecomastia (fatty tissue) which affects coverage determinations.

SourceEndocrine Society, 2022 (as cited in policy definitions).

ASPS Gynecomastia scale (Grade 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.

Policy Revision History

2025-08-01material_revisionLatest

Clarified coverage statement wording (tense/subject) to specify 'a mastectomy to treat Gynecomastia in a male is considered reconstructive and medically necessary when all of the [listed] criteria are met.'

2025-08-01material_revision

Changed supporting laboratory testing wording from mandatory ('must be performed') to permissive ('may include') when evaluating medical causes of gynecomastia.

2025-08-01

Policy Summary

PayerUnitedHealthcare

PolicyGynecomastia Surgery (for Tennessee Only)

Policy CodePolicy CS051TN.O

Change TypeRevised coverage criteria and laboratory testing guidance

Effective DateAugust 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for mastectomy (CPT 19300) and submit documentation showing all coverage criteria and supporting laboratory evaluation when applicable.

SourceLink

On This Page

Action for providerUse the policy's coding section or contact provider services for code-specific questions (CPT 19300 referenced elsewhere).

Document persistence of gynecomastia for the required duration (see Coverage Rationale).

Include supporting laboratory testing when performed (hormone panel, liver enzymes, serum creatinine, alpha-fetoprotein as applicable).

Documentation Required

Conservative Management Before Surgery

Conservative management and evaluation must be documented prior to surgery when applicable. This includes cessation of causative medications/supplements/substances and either watchful waiting for the required time period or documented failed medical therapy per specialty guidance.

For adolescents: observe duration and failed medical therapy timeframes per ASPS recommendations (see Coverage Rationale).
For adults: document at least the recommended trial/observation period and failed medical therapy as applicable.
Document cessation of prescribed medications, supplements, and relevant non-prescription/recreational substances with known association to gynecomastia.

Denial Risk

Denial Risk for Insufficient Clinical Criteria

Insufficient clinical documentation that does not show the required criteria (e.g., ASPS grade not documented, glandular tissue not confirmed, persistence not demonstrated, or missing evaluation of medical causes) places the request at risk for denial.

Missing ASPS grade (II–IV) or equivalent exam description may lead to denial.
If glandular tissue is not documented as the primary cause, benefit may be denied as pseudogynecomastia is not covered.
Failure to show persistence for the required duration may result in denial.

Denial Risk

Failure to Meet Revised Coverage Criteria May Result in Denial

Failure to meet the revised coverage criteria (including the updated permissive phrasing for laboratory testing and the requirement that documentation reflect all listed criteria) may result in denial of the request. Ensure submitted records address each coverage element.

Revised criteria require documentation showing an appropriate evaluation of medical causes; supporting labs may include but are not limited to the listed tests.
Ensure records explicitly map to each policy criterion to avoid incomplete-review denials.

Note

Provider Action — Submission Checklist to Support Prior Authorization

Provider action: When submitting prior authorization, include a clear checklist or summary that maps the member's clinical record to each policy criterion to facilitate review and reduce risk of incomplete or delayed decisions.

Attach physical exam notes documenting ASPS grade and glandular vs fatty tissue.
Attach imaging reports (mammography and/or ultrasound) if performed.
Attach medication/substance history and documentation of cessation or trial periods.
Attach laboratory results or note if testing was done and normal.
Include dates showing persistence duration and any conservative treatment timelines.

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

Functional or Physical Impairment — definition

DefinitionA Functional or Physical Impairment causes deviation from the normal function of a tissue or organ resulting in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities or basic life functions.

Coverage noteThe inability to participate in athletic events, sports, or social activities alone is not considered a Functional or Physical Impairment for coverage purposes.

SourceMedicare, 2023 definition referenced in policy; applied to assess 'moderate to severe chest pain causing a Functional or Physical Impairment' criterion.

Mastectomy to treat Gynecomastia in a male — definition

DefinitionMastectomy to treat Gynecomastia in a male: surgical removal of glandular breast tissue (mastectomy) performed to treat persistent gynecomastia when all coverage criteria are met.

Coverage contextConsidered reconstructive and medically necessary when criteria are met, including ASPS grade II–IV, glandular tissue as primary cause, persistence after cessation of causative agents, duration ≥2 years, and appropriate evaluation of medical causes with supporting labs.

Procedure code referencePolicy references CPT 19300 for mastectomy for gynecomastia in coding sections.

Updated examples of supporting laboratory tests: added thyroid function studies and sex‑hormone binding globulin, added alpha‑fetoprotein, and removed a prior mention of thyroid function studies in a different location.

2025-08-01nonmaterial_update

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

2025-08-01nonmaterial_update

Updated Clinical Evidence and References sections to reflect current supporting information.