Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecomastia status-post 19300 mastectomy
Treatment: Code 19300 mastectomy
The insurer denied coverage for: Code 19300 mastectomy
The denial is : Upheld
This is an adult with left breast lump. The patient underwent mammogram tomography which revealed gynecomastia in the left breast at 3 o'clock, retro areolar. In the right breast there was no new suspicious mass or calcification, or other abnormality noted. Ultrasound was also performed and demonstrated gynecomastia in the left breast without mammographic evidence of malignancy. The BiRads classification was category 2 for benign findings.

As per the progress note the patient is an adult with a nodule in the left breast, probably present for 4 months, increasing in size, and uncomfortable. The patient denied medications as well steroid use. The patient does drink 10 drinks per week. There is no family history of breast cancer. On exam of the breasts there was no asymmetry noted, no tethering, and no nipple changes. There were no nodes in the axillary, supra and infra clavicular area. The breast was palpated and there was no dominant mass in the left breast. There was some palpable abnormal tissue in the left breast keeping with gynecomastia. The provider reviewed the mammography and ultrasound and noted that only on ultrasound did there seem to be a small mass beneath the left nipple areolar complex. The assessment was adult with symptomatic gynecomastia. The patient wanted to proceed with gynecomastia excision.	

Based upon the records provided and review of the literature there is agreement that the mastectomy is not warranted in this patient for gynecomastia based upon the information provided. There is no evidence that is suspicion for a malignancy based upon the records or upon the notes by the provider. And if it was suspicious a biopsy would have been recommended. Instead, the patient wants the gynecomastia to be excised. There is no indication as noted by the insurer that it should be done. According to Milliman Care Guidelines (MCG) Health Ambulatory care 27th edition Mastectomy for gynecomastia ACG: A-0273 (AC) Mastectomy for gynecomastia may be indicated for 1 or more of the following: Post pubertal male and ALL of the following: Functional impairment (e.g., chronic skin irritation, pain, related psychological disorder requiring therapy);Gynecomastia did not regress after cessation of medications (e.g., calcium channel blockers, Cimetidine, phenothiazines, Spironolactone, Theophylline) known to cause condition, medications cannot be discontinued, or no medications that induce gynecomastia are being used; evidence of breast cancer; No evidence of other medical causes for gynecomastia, as indicated by normal results for ALL of the following: Hormone evaluation, Liver enzymes, Serum creatinine, Thyroid function tests; Pubertal male and ALL of the following: Functional impairment (e.g., chronic skin irritation, pain, related psychological disorder requiring therapy); Gynecomastia present for 2 or more years. There was no indication based upon these criteria that mastectomy should be performed for gynecomastia. There was no functional impairment; no known medications that causes it; no other medical causes for gynecomastia and the vague mass has only been present for 4 months. On mammography and ultrasound, it was labeled as Birads2 - benign. Therefore, there was no indication for mastectomy for this gynecomastia. 

Therefore, based upon the clinical information provided, the reviewer does feel that the mastectomy for gynecomastia is this patient is not warranted. The denial is upheld. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Code 19300 mastectomy for gynecomastia (removal of extra breast tissue) is not substantiated.