Breast tissue is composed of glandular tissue made up of ductal and stromal tissues, and fatty tissue made from adipocytes. Gynecomastia is considered the abnormal proliferation of breast tissue in male subjects. Although a small amount of breast tissue in male subjects is common, the visual appearance of breasts in a male subject is considered abnormal.1,2 The American Society of Plastic Surgeons recommends using the Gynecomastia Scale adapted from the McKinney and Simon, Hoffman and Kohn scales to diagnose the severity of gynecomastia, as follows: grade I, small breast enlargement with localized button of tissue that is concentrated around the areola; grade II, moderate breast enlargement exceeding areola boundaries with edges that are indistinct from chest; grade III, moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present; and grade IV, marked breast enlargement with skin redundancy.
The development of visible breasts in a healthy male subject can occur at any age, often leading to functional impairment and emotional distress. Pathologic gynecomastia caused by androgen/estrogen imbalance can occur in male subjects secondary to endocrine abnormalities, tumors, medication, genetic disorders, and other conditions.1,3,4 Adolescent gynecomastia initiated at puberty is reported in approximately 65 percent of boys, but tends to resolve in the majority of cases.1,2,5 Later in life, tissue proliferation can return or spontaneously occur in adulthood. Approximately 40 percent of healthy men have palpable breast tissue,4 and this is not considered pathologic.
Before treatment of gynecomastia, the physician completes a thorough history and physical examination of the patient to determine predisposition and timeline, imaging mammography to rule out malignancy, and blood tests to determine the presence of hormone imbalance or tumor. The type of treatment depends on the presented symptoms and individual history. If regression of the glandular breast tissues is not achieved spontaneously by terminating the drug associated with gynecomastia and/or with hormonal replacement, surgical excision of the tissue is often considered.4 The most common treatment for severe intractable gynecomastia is subcutaneous excision with liposuction, often with resection of the breast bud.6 Over the past decade, the annual rate of gynecomastia operations performed has increased dramatically from 1 percent to 36 percent,3 making this a very common procedure offered by most plastic surgeons in the United States.
The American Society of Plastic Surgeons has published guidelines for coverage criteria of plastic surgery procedures with the intention of distinguishing cosmetic from medically necessary operations. The American Society of Plastic Surgeons coverage recommendations3 for gynecomastia for adolescents and adults are summarized in Table 1. Although the recommendations of coverage for reduction mammaplasty in female subjects are more firmly grounded in scientific evidence,7–12 the recommendations for gynecomastia in male subjects are not supported by abundant literature. Insurance companies now play a larger role in determining coverage criteria for such medical procedures. Some insurers use third-party management companies, such as McKesson, to provide evidence-based guidance to form coverage policy. Due to the independent nature of U.S. insurance companies and the limited scientific evidence for breast reduction in male versus female subjects, there appears to be more variability in insurance coverage, with less stringent criteria for gynecomastia compared with reduction mammaplasty.
Until now, the correlation of insurance coverage requirements for gynecomastia surgery to established indications as determined by national recommendations has never been studied. The purpose of this article was to examine insurance company policies for gynecomastia surgery and determine whether the medical necessity criteria on which insurance companies’ decisions are made are consistent with current literature regarding the indications for this procedure.
Medical policies for gynecomastia reduction criteria were gathered from 61 insurance companies in the United States, including 60 private companies and Medicare. The providers were selected based on their market share, as reported by the National Association of Insurance Commissioners in 2017.13 A Web-based search was carried out, and policies were collected from each corresponding company’s website. Often, this policy was listed as a cosmetic procedure or located in the same document as female reduction mammaplasty. In addition, an online search using the keywords “gynecomastia,” “male mastectomy,” “reduction mammoplasty,” and “cosmetic surgery” was performed to extrapolate policies that were not readily available through the company’s website. If a policy was not located using any of the methods mentioned previously, a phone call was made to the company to locate the policy in question and, if confirmed by phone call that there was not established criteria for surgical intervention, we deemed the insurance company to not have a policy for gynecomastia.
Coverage policies were then reviewed in comparison to the current guidelines provided by the American Society of Plastic Surgeons.3 Each company policy was scrutinized with regard to whether they considered gynecomastia surgery strictly cosmetic and denied coverage in all instances. The companies that did offer coverage were evaluated for their requirements for coverage, as most companies evaluated the coverage on a case-by-case basis. We made special effort to check for inclusion of American Society of Plastic Surgeons–recommended guidelines, including gynecomastia grade. Other parameters in the policy were assessed, including body mass index, symptomatology, and prior treatments.
Policies were also evaluated for coverage across age groups. We evaluated each company’s gynecomastia policy to determine whether the company offered coverage to patients younger than 18 years. We then evaluated the adult and adolescent policy to highlight differences between the two.
Survey of Policies
Of the 61 policies reviewed in this study, 22 private providers and Medicare (n = 23, 37.7%) did not have defined coverage criteria for gynecomastia. These providers required prior authorization to be reviewed on a case-by-case basis and did not provide guidelines of requirements for what to include in the request to improve chances for coverage. Furthermore, three of these providers would only consider coverage if functional impairment (defined as a complete or partial inability to perform daily activities because of the existing breast enlargements and/or its associated symptoms) was clearly documented. Of the remaining 38 providers, gynecomastia reduction was considered strictly cosmetic and never covered by seven providers. The other 31 providers covered gynecomastia if their coverage requirements were satisfied (Fig. 1).
Medicare provides general and local coverage determinants for each procedure. In the case of gynecomastia, only local coverage determinants were available. A determination is made by a fiscal intermediary or carrier. Of the nine local coverage determinants found, reduction mammaplasty for gynecomastia was generally covered. However, coverage determinants varied from one carrier to another. Some of the most widely cited determinants included the following: presence of bilateral grade III or IV, pain or tenderness, and evidence of glandular nonfatty tissue.
All coverage criteria were determined by provider-specific internal policies, with the exception of Blue Cross Blue Shield of Minnesota, Wellmark Group, and Tufts Group. These three providers used third-party evidence-based clinical criteria developed by McKesson. The McKesson’s InterQual questionnaire for gynecomastia consists of two screening steps. For unilateral or bilateral gynecomastia, all of the following must be present: breast pain or tenderness; grade II, III, or IV gynecomastia; radiographically negative for cysts/tumors; and contributory conditions excluded for 6 months or longer. In addition, the patient’s medications must either be deemed noncontributory, contributory but discontinued, or contributory but medically required and cannot be changed/discontinued.
Only 14 (36.8 percent) of the 38 providers with a defined policy mentioned pubertal gynecomastia in their coverage. These 14 policies would cover gynecomastia surgery in a patient younger than 18 years if their adolescent coverage requirements were met. The current American Society of Plastic Surgeons coverage recommendations for adolescent patients are classified based on the modified McKinney and Simon, Hoffman and Kohn Scale as follows: (1) unilateral or bilateral grade II or III persisting more than 1 year after pathologic causes were ruled out, or 6 months of failed treatment; and (2) unilateral or bilateral grade IV persisting more than 6 months after pathology has been ruled out, or 6 months of failed therapy. Grading was considered a major criterion by eight of these 14 providers (57 percent), and only five of those eight covered all grades (II, III, and IV). One company, Blue Cross Blue Shield of Tennessee, did not require grading, but specified that there must be documentation of breast tissue greater than 4 cm. All providers, except for Highmark Group, generally defined a minimum duration for presence of breast enlargement of 2 years.
Although ruling out pathologic causes was unanimously required by all providers, the duration of symptoms in relation to timing of pathologic clearance was specified in only three policies: persisting for 2 years (n = 2) or 1 year (n = 1) after disease has been ruled out. Discontinuation of drugs associated with gynecomastia manifestation was required by 12 providers (85 percent), with an overall duration of discontinuation for 6 to 12 months before surgical evaluation. Alternatively, seven policies (50 percent) provide coverage if symptoms were refractory to medical therapy (use of tamoxifen or removal of offending drug) after an average 1 year of treatment.
The third American Society of Plastic Surgeons coverage criteria recommendation for adolescents is the presence of physiologic and psychological distress. Symptomatic involvement was required by 10 of the 14 providers (71 percent), described as pain (n = 8) and emotional distress (n = 2). Of these providers, presence of significant functional impairment was clearly stated in four policies (28.5 percent). Table 2 summarizes medical policies of insurance companies that will consider coverage for prepubertal gynecomastia.
Of the 38 providers, a total of 31 (81 percent) provide coverage for postpubertal and adult patients. Table 3 summarizes the criteria gathered from these providers. American Society of Plastic Surgeons coverage recommendations for this age group address only unilateral or bilateral grade III and IV, persisting more than 3 to 4 months after pathologic clearance, or 3 to 4 months of unsuccessful medical treatment of underlying disease. Fourteen of the 31 providers (45 percent) mandate presence of either grade III or IV gynecomastia. An additional seven policies (22 percent) covered grade II and IV, but also covered grade II in this age group. Blue Cross Blue Shield of Tennessee provided a measurement requirement of an average 4-cm increase in breast size, instead of a grading requirement.
With regard to symptomatic duration, only 16 policies of the 31 companies with coverage policies (51 percent) stated a minimum duration with an average of 1 year. The duration of symptoms required after pathologic clearance was described by four providers (13 percent) as persisting for 3 to 4 months, 6 months, 1 year, and 2 years after any underlying disease has been ruled out. Aside from Premera Blue Cross Group, all policies mentioned the need to discontinue gynecomastia-inducing medications by a minimum 1 month before consideration for surgery. One company required the maximum observed duration of 12 months of drug discontinuation before surgery. For those patients with an underlying pathologic condition, 22 providers (70 percent) require them to provide documentation of failure to respond to medical therapy (use of tamoxifen or removal of offending agent) for an average of 6 months.
Physical distress, but not psychological distress, is among the coverage criteria recommended by the American Society of Plastic Surgeons for adults. Overall, the presence of pain and discomfort was required by 22 covering providers (70 percent). In contrast to adolescents, the American Society of Plastic Surgeons recommended performing biopsy when malignancy is suspected in adults. Only four covering providers (13 percent) describe ruling out malignancy as a requirement for coverage; the remainder of the providers report the possibility of mammogram and biopsy coverage in cases of suspected malignancy.
Additional Variables Considered
As a significant proportion of insurance companies reviewed coverage for surgical management of gynecomastia on a case-by-case basis, the plastic surgeon must compile a complete history and physical examination of the patient. During our investigation, we discovered a variety of factors that insurance companies deemed necessary in their evaluation. The information listed in Table 4 should be included in the preauthorization request when petitioning for coverage of gynecomastia surgical intervention. In addition, photographic evidence is recommended to support the claim. In fact, policy providers for four adolescents (28.5 percent) and seven adults (22 percent) clearly indicated that photographic evidence is mandatory for coverage considerations.
In the physical examination, it is important to document body mass index, height, and weight. Body mass index less than 30 kg/m2, otherwise stated as “no obesity,” is required by two adolescent (14 percent) and 10 adult (32 percent) providers. Two providers of both adolescent and adult coverage (14 percent and 6 percent, respectively) required a body mass index less than 25 kg/m2 (“not overweight”).
Insurance companies recognize that breast tissue is composed of glandular, fibrous, and adipose tissues in their definition of gynecomastia. However, 85 percent of companies with defined gynecomastia policies require the presence of glandular tissue proliferation. These companies suggest histologic confirmation of the “presence of nonfatty, glandular breast tissue,” for all gynecomastia patients seeking coverage for reduction mammaplasty.
Some providers have additional qualifiers that can dismiss coverage, despite proof of medical necessity. For example, we observed two adult providers (6 percent), namely Blue Cross Blue Shield of South Carolina and Harvard Pilgrim Healthcare Group, who stated that any “previous history of alcohol or illicit drug abuse” is grounds for denial of coverage.
Generally, excision of breast tissue with liposuction is needed for complete treatment of gynecomastia. Therefore, we evaluated the policy for liposuction coverage requirements. Overall, five of the 14 policies for adolescent coverage (35 percent) and nine of the 31 adult policies (29 percent) do not cover liposuction under any circumstances. Four adolescent (28.5 percent) and six adult (19 percent) policies provide liposuction coverage only when performed in conjunction with mastectomy. The remaining five (35 percent) adolescent and 14 (45 percent) adult providers did not specify liposuction involvement in their policies, and thus, it is not clarified in the policy whether the company will cover the entire procedure of excision and liposuction, requiring case-by-case inquiry.
Based on the results of this study, we formatted a comprehensive list of recommended key elements to include in the patient report when filing for coverage (Table 5). We also compiled a list of the various means of surgical management of gynecomastia and their CPT codes3,14 to be used by medical practices for insurance reimbursement (Table 6).
Many insurance companies do not have a published policy for coverage of gynecomastia corrective procedures and must evaluate cases individually. This lack of structure is frustrating for plastic surgeons, who are not certain of the criteria that each individual company requires. The 38 companies with existing policies use the American Society of Plastic Surgeons definition and diagnosis of gynecomastia but have additional guidelines and requirements for coverage of reduction mammaplasty in male subjects. Of these 38 insurance carriers, seven companies have a policy to not provide coverage under any circumstances, forcing patients to pay out-of-pocket for the procedure.
Policies for breast reduction in female patients have better-defined coverage criteria and greater standardization compared to policies for male patients. This is most likely because of the limited literature supporting symptomatology associated with gynecomastia and the success of reduction mammaplasty in providing symptom relief. There is, however, more abundant scientific evidence that reduction mammaplasty is effective at reducing symptomatic breast hypertrophy in female patients.9,11,12 The American Society of Plastic Surgeons even provides International Classification of Diseases, Tenth Revision, categories for headache, back pain, breast pain, and other symptoms associated with hypertrophic breasts.7 In addition, the literature in support of female breast reduction states that resection volume does not correlate with degree of symptom relief.8,10 This correlation should be extrapolated to male gynecomastia. This would allow the physician and the patient more freedom to determine the best surgical plan while maintaining peace of mind that the procedure will be covered.
Despite establishing guidelines for coverage, many insurance companies do not follow the American Society of Plastic Surgeons criteria for identifying candidates for gynecomastia treatment. For example, the American Society of Plastic Surgeons has its own recommendation guidelines for coverage criteria for adults and adolescents; however, only 14 of the 61 insurance companies have a clear adolescent policy. Physicians recognize the difference in causes, symptoms, and treatment plans for adolescents versus adults. Many insurance companies require proof of medical therapy in adolescents, which is not supported by much literature. Unlike adult gynecomastia, many prepubertal cases of gynecomastia often resolve, with approximately 5 percent persisting and requiring intervention; however, only three providers specified a duration of symptom progression after ruling out disease in their requirements for adolescent coverage.
There are many different techniques for surgical management of gynecomastia. Our findings indicate that there is a discrepancy between insurance providers’ coverage of procedures and those recommended by plastic surgeons. Recent studies have reported that combination of subcutaneous excision with liposuction provides the most satisfactory outcomes. When there is very little glandular tissue, patients can opt for a less invasive procedure that involves liposuction on its own.6 Liposuction forms an integral part of many gynecomastia surgical cases, therefore we evaluated the policies for liposuction coverage requirement and found that most insurance companies do not have a policy on this popular surgical intervention (35 percent of adolescent policies; 45 percent of adult policies). The companies that do have a policy may not cover liposuction (35 percent adolescent; 29 percent adult), thus limiting coverage of the less invasive liposuction procedure.
Third-party management companies, such as McKesson, provide evidence-based clinical criteria for various conditions. InterQual questionnaires developed by McKesson are widely used as screening tools for coverage requirements by many insurance providers. Our observations conclude that McKesson’s InterQual criteria for gynecomastia are consistent with current American Society of Plastic Surgeons coverage standards for adults. However, InterQual is only designated for adult patients (older than 18 years) and therefore does not fully comply with American Society of Plastic Surgeons standards in covering adolescents.
Current insurance company medical policies for gynecomastia procedures are uniformly inconsistent with current coverage standards by the American Society of Plastic Surgeons. As a result, patients that are deemed candidates for medically-necessary surgical correction of gynecomastia are deprived of insurance coverage for this procedure. Most insurance companies with a policy in place require specific patient details when evaluating the case for coverage. Based on the results of this study, we formatted a comprehensive list of recommended key elements to include in the patient report when filing for coverage. The recommendations compiled from the evaluation are in line with the recommendations of the American Society of Plastic Surgeons and include insurance policy details. However, because of the wide variety in medical plans and the possible changes in company policies, this table may not be applicable to all cases. We also compiled a list of the various means of surgical management of gynecomastia and their CPT codes14 to be used by medical practices for insurance reimbursement.
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©2019American Society of Plastic Surgeons
14. Janevicius R. Breast reduction coding should be straight forward, not confusing. Available at: file:///C:/Users/Frank/Downloads/BreastReductionCodingShouldBeStraightForwardnotconfusinOP.pdf. Accessed March 22, 2019.