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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral mastectomy. According to the American Society of Plastic Surgeons (ASPS), gynecomastia is defined as the presence of an abnormal proliferation of breast tissue in males. However, the ASPS noted that, in pseudogynecomastia, the breast enlargement is secondary to fat accumulation; and both glandular and fat tissue are present in mixed gynecomastia. Gynecomastia is different from pseudogynecomastia, which is an increase in subareolar fat often related to obesity. True gynecomastia has a palpable firm disc of tissue under the nipple areolar complex. Studies noted that in pseudogynecomastia, there is an increased development of the fatty component in the male breast region. The aims of surgery include the elimination of painful breast tissue and restore the patients chest to an acceptable shape. This patient presents with bilateral breast enlargement. Glandular gynecomastia is present on the right and is described as moderate. His BMI is 27.04 kg/m2. The patient complains of tenderness and pain, but there is no report of pain and discomfort due to the distention and tightness from the hypertrophied breast. Following physical examination, the providers impression included moderate right gynecomastia, for which he recommended surgery on the right side. The glandular volume is moderate and does not reach grade III or IV gynecomastia. Moreover, the glandular gynecomastia is not concerning for malignancy. The remainder of the right breast volume on the right side is pseudogynecomastia, similar to the left side. The patients breast enlargement on the left is not consistent with glandular gynecomastia on ultrasound and physical examination. Based on the medical information received for review, this patient does not meet the ASPS criteria for bilateral mastectomy. Therefore, the requested bilateral 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; or (2) to create a normal appearance, to the extent possible. In this case, the enlargement of the left breast is from pseudogynecomastia and is the result of fatty tissue fullness, and it is not an abnormal structure of the body. Although the fatty enlargement of the right breast is not an abnormal structure of the body, the glandular gynecomastia in the patients right breast is an abnormal structure of the body caused by a developmental abnormality. Tenderness is present, but pain is not documented in the medical records provided for review. In addition, there is no documentation of loss of function. The appearance of the breasts with regard to symmetry is within the range of normal. Any surgery to remove the right gynecomastia would not provide more than a minimal improvement in the appearance of the patient. Thus, the requested bilateral mastectomy is not reconstructive in nature for treatment of 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.