CurrentUnitedHealthcarePolicy CS051KS.02

Gynecomastia Surgery (for Kansas Only)

Policy governs surgical treatment of gynecomastia for members in Kansas and describes when such surgery is considered reconstructive and medically necessary; it affects providers and payers administering UnitedHealthcare benefits in Kansas.

Policy Summary

PayerUnitedHealthcare

PolicyGynecomastia Surgery (for Kansas Only)

Policy CodePolicy CS051KS.02

Change TypeOperational updates

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionConfirm InterQual CP: Reduction Mammoplasty, Male (or Adolescent) criteria prior to requesting prior authorization for surgical treatment.

SourceLink

POLICY UPDATE CHANGES

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

Applicable Codes section was updated.

Archived previous policy version CS051KS.01.

1CPT procedure code listed (19300)

KansasState-specific application

InterQualPrimary clinical criteria source

Coverage Criteria

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InterQual requirement: Surgical treatment of gynecomastia is considered reconstructive and medically necessary when the InterQual CP clinical criteria for Reduction Mammoplasty, Male or Reduction Mammoplasty, Male (Adolescent) are satisfied.use InterQual specifics

Refer to InterQual for the full clinical entry; this policy delegates the medical necessity determination to InterQual.

This FDA information is provided for background only. Surgeries for the treatment of gynecomastia are procedures and therefore not regulated by the U.S. Food and Drug Administration; FDA approval status is informational and is not a basis for coverage. Providers may refer to the FDA PMN database for procedural device information if needed: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm.

Surgical treatment of gynecomastia that does not meet the InterQual® Clinical Pathway (CP) criteria for Reduction Mammoplasty, Male or Reduction Mammoplasty, Male (Adolescent) is not medically necessary under this policy. Providers should confirm that the case meets the applicable InterQual entry before pursuing authorization or scheduling surgery.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required and is tied to InterQual clinical criteria. Surgical treatment of gynecomastia is considered reconstructive and medically necessary only when it meets the applicable InterQual CP: Reduction Mammoplasty, Male or InterQual CP: Reduction Mammoplasty, Male (Adolescent) criteria. Providers should obtain prior authorization before scheduling the procedure.

Affected InterQual criteria: Reduction Mammoplasty, Male; Reduction Mammoplasty, Male (Adolescent)
Prior authorization required before surgery
Reference InterQual criteria link for clinical detail

Documentation Required

Documentation and Denial Risk

Documentation submitted with the prior authorization request must support that the InterQual clinical criteria are met and must also be consistent with applicable federal, state, and contractual benefit requirements. UnitedHealthcare may deny claims if the InterQual clinical criteria are not met or if required documentation is not provided.

Clinical documentation should explicitly reference InterQual criteria met
Include relevant history, physical exam findings, prior treatments, and indications for reconstructive surgery
Verify and follow any state- or contract-specific documentation or coverage requirements

Background

Gynecomastia is enlargement of male breast tissue. Surgical options for management include procedures such as mastectomy for gynecomastia. UnitedHealthcare determines medical necessity for reconstructive surgery for gynecomastia by referencing the InterQual® CP criteria for Reduction Mammoplasty, Male and Reduction Mammoplasty, Male (Adolescent); see the InterQual entry for the full clinical criteria and guidance.

When applying these criteria, note that FDA regulation does not apply to surgical procedures themselves; the FDA note in this policy is informational only and does not affect the InterQual-based medical necessity determination.