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Date Printed: December 17, 2017: 10:06 PM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-12000-14

Original Effective Date: 05/15/01

Reviewed: 05/28/09

Revised: 11/01/15

Subject: Mastectomy for Gynecomastia

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions
           
Other References Updates    
           

DESCRIPTION:

Gynecomastia is a benign enlargement of the male breast due to proliferation of the glandular component. Gynecomastia may be an incidental finding on routine examination, may present as an acute unilateral or bilateral painful tender mass beneath the areolar region, or as a progressive painless enlargement of the breast. Mastectomy for gynecomastia is a surgical procedure performed to remove breast glandular tissue from a male with enlarged breast.

Bilateral gynecomastia may be associated with any of the following:

Treatment of gynecomastia involves consideration of the underlying cause. For example, treatment of the underlying hormonal disorder, cessation of drug therapy or weight loss may all be effective therapies. Adolescent gynecomastia may resolve with aging. Surgical removal of the breast tissue, using either surgical excision or liposuction may be considered if the above conservative therapies are not effective or possible. Most patients with gynecomastia require no therapy other than the removal of identified cause.

POSITION STATEMENT:

All requests for mastectomy for gynecomastia are reviewed to rule out cosmetic verses medical necessity. Photos should be maintained as part of the medical record, refer to section entitled REIMBURSEMENT INFORMATION.

Mastectomy for gynecomastia meets the definition of medical necessity when ALL of the following exist:

NOTE: Liposuction performed as an adjunct procedure to a surgical mastectomy may be considered an appropriate treatment option.

Mastectomy for gynecomastia is considered cosmetic in nature and is generally a contract exclusion for the following indications:

Liposuction as the sole procedure for reduction mammaplasty or breast reduction is considered experimental or investigational as there is insufficient clinical evidence to support the use of liposuction as the sole procedure for all indications. There is limited published clinical data evaluating the effectiveness and long-term results of liposuction and few case studies regarding the effect of breast reduction by liposuction on patient outcomes.

BILLING/CODING INFORMATION:

CPT Coding:

19300

Mastectomy for gynecomastia

ICD-10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

N62

Hypertrophy of the breast

REIMBURSEMENT INFORMATION:

Required Documentation

The primary treating physician MUST submit the following information:

NOTE: Photos are not required with the initial review. Photos should be maintained as part of the medical record. BCBSF may request photos as part of the review process.

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment and reason for mastectomy for gynecomastia.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No Local Coverage Determination (LCD) or National Coverage Determination (NCD) for mastectomy for gynecomastia.

DEFINITIONS:

No guideline related definitions apply.

RELATED GUIDELINES:

OTHER:

None applicable.

REFERENCES:

  1. American Society of Plastic Surgeons Position Statement, 1994.
  2. American Society of Plastic Surgeons Practice Guidelines, 1996.
  3. Blue Cross Blue Shield Association Medical Policy. Surgical Treatment of Bilateral Gynecomastia, 04/15/02, 10/09/03.
  4. First Coast Service Options, Inc., LCD for Reduction Mammaplasty (L15708), 07/05.
  5. Hayes, Inc., Hayes Directory, Tumescent Liposuction, Update 10/06.
  6. InterQual, Inc., Reduction Mammoplasty (male), 2000, 10/03.
  7. InterQual, Procedures Criteria Reduction Mammoplasty (Male), 2006.
  8. The New England Journal of Medicine, Current Concepts: Gynecomastia, Feb 18, 1983, V0l.328, No.7.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/28/09.

GUIDELINE UPDATE INFORMATION:

05/15/01

Medical Coverage Guideline reformatted.

06/15/03

Annual review. Added coverage and non-covered statement for liposuction.

06/15/05

Scheduled review. No change in coverage statement. Revised description section to include information regarding bilateral gynecomastia. Updated references.

06/15/06

Deleted the requirement of photographs for documentation.

07/15/06

Added note regarding maintaining photos as part of the medical record.

01/01/07

HCPCS update. Deleted 19140. Added 19300.

06/15/07

Annual review; maintained current coverage and limitations; reformatted guideline; Medicare Advantage section updated; references updated.

04/15/09

Deleted program exception statement for Medicare Advantage product.

06/15/09

Annual review; maintain position statements. Updated references.

02/15/11

Revision; related ICD-10 code added.

10/01/11

Revision; formatting changes.

05/11/14

Revision: Program Exceptions section updated.

07/15/15

Revision: Program Exceptions section updated

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: December 17, 2017: 10:06 PM