CurrentUnitedHealthcarePolicy MP.012.20

Mastectomy to treat Gynecomastia (male)

Defines clinical criteria under which mastectomy to treat gynecomastia in males (both under 18 and aged 18 and over) is considered reconstructive and medically necessary for UnitedHealthcare commercial and individual exchange plans; includes required evaluations, supporting laboratory testing examples, applicable CPT code, benefit considerations, and references.

Policy Summary

PayerUnitedHealthcare

PolicyMastectomy to treat Gynecomastia (male)

Policy CodePolicy MP.012.20

Change TypeRevisions to coverage criteria and lab testing language

Effective DateJul 1, 2025

Next Review Date

Key ActionDocument ASPS/grade II-IV gynecomastia and that moderate to severe chest pain causes a Functional or Physical Impairment; inability to participate in sports/social activities alone does not meet impairment criterion.

POLICY UPDATE CHANGES

Replaced generalized coverage statement wording to specify 'a mastectomy to treat Gynecomastia in a male is considered reconstructive and medically necessary when all of the [listed] criteria are met'.

Revised coverage criteria wording for evaluation and supporting laboratory testing from a requirement that tests 'must be performed' to 'supporting laboratory testing may include but is not limited to the [listed tests]'.

Updated list of supporting laboratory tests: added 'thyroid function studies' and 'sex-hormone binding globulin', added 'alpha-fetal protein', and removed a duplicate instance of 'thyroid function studies'.

Removed reference link to the Medical Policy titled 'Panniculectomy and Body Contouring Procedures' from Related Policies and Applicable Codes.

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

1Primary CPT code listed

3Required supporting lab test categories (examples)

II-IVGynecomastia grades eligible when criteria met

Coverage Summary

Defines clinical criteria under which a mastectomy to treat Gynecomastia in males (both under age 18 and age 18 and over) is considered reconstructive and medically necessary for UnitedHealthcare commercial and individual exchange plans when all listed criteria are met. Effective date: 2025-07-01. Policy number: MP.012.20. Coverage stance: covered_with_criteria.

Quick facts — Mastectomy for Gynecomastia

Primary CPT code listed19300

Gynecomastia grades eligible when criteria metII-IV

Required supporting lab test categories (examples)Hormone testing; Liver enzymes; Serum creatinine; Alpha-fetal protein (categories = 3+)

Duration threshold (males under 18)>= 2 years

Coverage stanceCovered with criteria (mastectomy considered reconstructive and medically necessary when all listed criteria met)

Confidence (policy document)0.95

Medical Necessity Criteria

Mastectomy to treat Gynecomastia (male under age 18)

Covered when ALL of the following are met:

ALL of the following

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)
Glandular breast tissue is the primary cause of Gynecomastia as opposed to fatty deposits (pseudogynecomastia) and is documented on physical exam and/or mammography
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)

Provider Actions & Documentation Required

Documentation Required

Document gynecomastia stage and impairment

Document ASPS/grade II-IV gynecomastia and that moderate to severe chest pain causes a Functional or Physical Impairment; note that inability to participate in sports/social activities alone does not meet impairment criterion.

Documentation Required

Document glandular tissue and imaging

Document that glandular breast tissue (not pseudogynecomastia) is primary cause via physical exam and/or mammography; if tumor suspected, perform breast ultrasound and/or mammogram and manage accordingly.

Coding

Applicable Procedure CodesCPT

19300

Mastectomy for gynecomastia

Background & Evidence

Mastectomy for gynecomastia is intended to remove glandular breast tissue in males after evaluation and when reconstructive/medical necessity criteria are met. Treatment follows evaluation for physiologic and non-physiologic causes, discontinuation of contributing medications or substances, and appropriate medical or imaging workup before surgical consideration.

Benefit plan coverage varies: most benefit plans explicitly exclude treatment of benign gynecomastia, but some state mandates may require coverage; members’ specific benefit plan documents should be consulted to determine benefit availability.

Surgical approaches and outcomes vary (open excision, liposuction-assisted, combined techniques, and skin-sparing mastectomy among others) and evidence is limited. Systematic reviews and reviews of the literature report improvements in patient satisfaction and quality of life with liposuction-assisted and combined techniques, variable complication and reoperation rates, and no universally accepted algorithm for the ideal surgical approach. Evidence on mastectomy specifically is largely single-arm studies, and guidance from clinical practice statements is mixed or limited, supporting careful evaluation and selection for surgery.

Source	Summary
Hayes Evidence Analysis (2024)
Eight abstracts identified; evidence largely single-arm studies; guidance unclear for mastectomy
Systematic reviews (Prasetyono 2022; Innocenti 2022)
Prasetyono: liposuction-assisted techniques show consistent QoL improvement; complication rates variable; Innocenti: combined techniques may reduce complications versus excision alone
ASA/EAA and ASPS guidance
Recommend evaluation to rule out underlying pathology; surgical treatment for persistent gynecomastia after medical therapy or watchful waiting per grade/duration criteria

Gynecomastia: Breast enlargement in boys or men due to a benign increase in breast tissue (Endocrine Society, 2022).

ASPS Gynecomastia scale - Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest.

ASPS Gynecomastia scale - Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present.

ASPS Gynecomastia scale - Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast.

Revision History

07/01/2025revisedLatest

Replaced prior generalized coverage statement wording with specific wording: 'a mastectomy to treat Gynecomastia in a male is considered reconstructive and medically necessary when all of the [listed] criteria are met'.

07/01/2025revisedLatest

Revised coverage criteria operational requirement: changed wording from tests 'must be performed' to 'supporting laboratory testing may include but is not limited to the [listed tests]'.

07/01/2025

Policy Summary

PayerUnitedHealthcare

PolicyMastectomy to treat Gynecomastia (male)

Policy CodePolicy MP.012.20

Change TypeRevisions to coverage criteria and lab testing language

Effective DateJul 1, 2025

Next Review Date

On This Page

Gynecomastia must be present for at least two years>= 2 years

ALL of the following

Examples of supporting laboratory testing
- 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 age 18 and over)

Covered when ALL of the following are met:

Documentation Required

Document medication/substance cessation and persistence

Document persistence of gynecomastia after cessation of prescribed medications, supplements, and screening for non-prescription/recreational substances known to cause gynecomastia.

Documentation Required

Document laboratory evaluation

Provide results of an appropriate evaluation of medical causes with supporting laboratory testing shown to be normal; include relevant hormone tests, liver enzymes, serum creatinine, and alpha-fetal protein as applicable.

Functional or Physical Impairment: Causes deviation from normal function of a tissue or organ resulting in a significantly limited capacity to move, coordinate actions, or perform physical activities; exhibited by difficulties in physical/motor tasks, independent movement, or basic life functions.

Edited example supporting laboratory tests: updated hormone-testing examples to add 'thyroid function studies' and 'sex-hormone binding globulin', added 'alpha-fetal protein', and removed a duplicate 'thyroid function studies'.

07/01/2025removedLatest

Removed reference link to the Medical Policy titled 'Panniculectomy and Body Contouring Procedures' from Related Policies and Applicable Codes.

07/01/2025updatedLatest

Updated Clinical Evidence and References sections to reflect the most current information (Hayes brief and recent systematic reviews added).