Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for mastectomy. Gynecomastia is defined as the presence of an abnormal proliferation of breast tissue in males with a broad range of causes that are classified as either physiological or pathological, although in many cases no specific cause can be found. In true gynecomastia, the breast enlargement is due to glandular breast tissue while in pseudogynecomastia, the breast enlargement is secondary to fat accumulation. Both glandular and fat tissue are present in mixed gynecomastia. Gynecomastia is to be differentiated from pseudogynecomastia, an increase in subareolar fat often related to obesity. True gynecomastia has a palpable firm disc of tissue under the nipple areolar complex. The records provided for review document that this patient has breast enlargement after rapid massive weight loss. There is no report of physical examination documenting glandular gynecomastia, medical evaluation of possible causes of gynecomastia, mammography findings reporting glandular gynecomastia in contrast to pseudogynecomastia, or evidence of a hormonal evaluation. Researchers stated that, in both hypothyroidism and hyperthyroidism, gynecomastia is commonly resolved after euthyroid state restoration. Recommended laboratory investigations to find the underlying cause of gynecomastia include liver enzymes, serum creatinine, and thyroid stimulating hormone levels, which are not provided in the records reviewed. There is no report of medication use that could cause gynecomastia. Per the American Society of Plastic Surgeons (ASPS), this patient does not meet the criteria for mastectomy. There is no reported suspicion of malignancy. Bilateral breast enlargement is present consistent with grade IV gynecomastia, but there is no report of a physical examination to rule out pseudogynecomastia due to residual fat. Thus, the possible pathological causes of gynecomastia have not been ruled out. In addition, there is no report of pain and discomfort due to distension and tightness from a hypertrophied breast. All told, the requested mastectomy is not medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. This patient does not have a confirmed diagnosis of glandular gynecomastia as a cause of his breast size after rapid massive weight loss. There is no determination received for review that his breast size is caused by a congenital defect, a developmental abnormality, trauma, infection, tumors, or disease. The records do not support the presence of a functional deficit related to the presence of gynecomastia. Furthermore, the requested mastectomy would not provide a more than minimal improvement in the appearance of the patient. For these reasons, the requested mastectomy is not reconstructive in nature for this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.