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

Nature of Statutory Criteria/Case Summary: The patient is requesting authorization and coverage for bilateral mastectomy gynecomastia surgery. The Health Plan has denied the request as not medically necessary for treatment of the patients medical condition.Gynecomastia is defined as the presence of an abnormal proliferation of breast tissue in males. It is a common breast lesion, accounting for more than 655 of male breast disorders. Gynecomastia has 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; in pseudogynecomastia, the breast enlargement is secondary to fat accumulation; and 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.According to the American Society of Plastic Surgeons Recommended Insurance Coverage Criteria for Third-Party Payers, Gynecomastia, recommended criteria for excision of gynecomastia in adults are as follows:1.    A breast biopsy is indicated when malignancy is suspected.2.    Unilateral or bilateral grade III or IV gynecomastia present:persists more than three to four months after pathological causes ruled out,persists after three to four months of unsuccessful medical treatment for pathological gynecomastia,3.    Pain and discomfort due to the distention and tightness from the hypertrophied breast.       Gynecomastia Scale:Grade I Small breast enlargement with a localized button of tissue that is concentrated around the areola,Grade II Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest,Grade III Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present,Grade IV Marked breast enlargement with skin redundancy and feminization of the breast.Malignancy is not suspected for this patient, and there is a history of a benign breast biopsy in the past. The patient has breast enlargement on photos equivalent to grade III gynecomastia, although physical examination reports a palpable breast bud on the right and a smaller tender bud on the left. Small breast buds would not constitute grade III gynecomastia, and it appears that the patient has largely pseudogynecomastia at a BMI of 29.7, with true gynecomastia at grade I-II. He reports occasional discomfort during daily work, but there is no report of pain and discomfort due to the distention and tightness from the hypertrophied breast. Based on the medical information received for review, the bilateral mastectomy gynecomastia surgery is not medically necessary.Final Result: The reviewer determined that the requested service is not medically necessary 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.