CurrentUnitedHealthcarePolicy CS051FL.Q

Gynecomastia Surgery (for Florida Only)

This policy governs UnitedHealthcare coverage guidance for gynecomastia surgery applicable only to members in Florida, directing readers to Florida Medicaid Integumentary Services Coverage Policy for clinical criteria.

Policy Summary

PayerUnitedHealthcare

PolicyGynecomastia Surgery (for Florida Only)

Policy CodePolicy CS051FL.Q

Change TypeMaterial revision — defers criteria to external policy

Effective DateSep 1, 2025

Next Review Date

Key ActionFollow the Florida Medicaid Integumentary Services Coverage Policy for prior authorization and medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

Replaced coverage guidelines with instruction to refer to the Florida Medicaid Integumentary Services Coverage Policy for medical necessity clinical coverage criteria.

Removed definitions of Gynecomastia and Functional or Physical Impairment.

Removed Description of Services and Clinical Evidence sections.

Updated reference link for Panniculectomy Surgery related policy.

Florida-onlygeographic applicability

19300listed procedure code

Defers to Florida Medicaidcoverage criteria source

CS051FL.Qpolicy id

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Coverage Criteria

Medical necessity (external reference)

Coverage is determined by meeting the medical necessity clinical coverage criteria referenced below:

Referenced criteria: All medical necessity criteria in the Florida Medicaid Integumentary Services Coverage Policy must be met for coverage.

This policy does not enumerate the criteria itself and requires referral to the specified Florida Medicaid policy.

This policy clarifies that surgical procedures, including those performed for gynecomastia, are considered procedures and are not regulated as medical devices by the U.S. Food and Drug Administration. Accordingly, FDA approval information alone is not a basis for coverage under this policy; FDA status is provided for informational purposes only.

Listing a procedure or diagnosis code in this policy is for reference only and does not imply the service is covered. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claim payment. Coverage and payment determinations are governed by applicable federal, state, or contractual requirements and laws; services that do not meet those governing requirements may be excluded from coverage.

Coding

Listed CPT CodesCPT

19300

Mastectomy for gynecomastia

Provider Actions / Prior Authorization

Prior Authorization

Refer to Florida Medicaid clinical criteria for authorization

Prior authorization or coverage determinations should follow the Florida Medicaid Integumentary Services Coverage Policy for medical necessity. Refer to that policy for detailed clinical criteria when requesting authorization.

Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws — in a conflict those requirements govern.
UnitedHealthcare may use third-party tools (e.g., InterQual) to assist in administering benefits.

Step Therapy

Step therapy

No step therapy requirements are specified in this policy document.

Background

This policy addresses surgical management of gynecomastia (male breast tissue reduction) for members in Florida. It does not set its own medical necessity criteria; coverage is determined by meeting the medical necessity clinical coverage criteria in the referenced Florida Medicaid Integumentary Services Coverage Policy. Providers must follow the referenced Florida Medicaid criteria and applicable federal, state, or contractual requirements when requesting authorization or submitting claims.

Definitions

DEFINITIONS — Removed

Definitions removedThe policy no longer includes definitions for 'Gynecomastia' and 'Functional or Physical Impairment'.

Effective change date09/01/2025 — definitions removed as part of policy revision.

Scope of removalDefinitions removed from the policy text; refer to external references (e.g., Florida Medicaid policy) for clinical definitions.