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 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.  

The rules say that the documentation requirements for mastectomy for gynecomastia are:  

-Glandular breast tissue confirming true gynecomastia is documented on physical exam and/or mammography 
-Documentation that the gynecomastia persists, despite correction of any underlying causes 
-Documentation supporting that the gynecomastia is classified as Grade III or IV per the American Society of Plastic Surgeons classification 
-Documentation that hormonal causes, including hyperthyroidism, estrogen excess, hyperprolactinemia and hypogonadism have been excluded by appropriate laboratory testing (e.g. with levels of thyroid stimulating hormone [TSH], estradiol, prolactin, testosterone and or luteinizing hormone [LH]) 
-Documentation supporting that gynecomastia persists after 6 months of unsuccessful medical treatment, the use of potential gynecomastia-inducing drugs and substances has been ruled out and gynecomastia persist for at least one year. (ASPS)  

You can find this rule in the in the Local Coverage Article (LCA) - Billing and Coding: Cosmetic and Reconstructive Surgery (A58774) - Effective November 25, 2021.  

The rules say that gynecomastia is the excessive growth of the male mammary glands. These conditions can cause significant clinical manifestations when the excessive breast weight adversely affects the supporting structures of the shoulders, neck, and trunk. Mastectomy with nipple preservation or reduction mammoplasty is considered reconstructive and a covered service for males with gynecomastia Grade III and IV or abnormal breast development with redundancy.  

-Persists more than 3 to 4 months after the pathological causes are ruled out (e.g. not limited to testosterone deficiency, testicular tumor, liver disease, or drug induced).34 
-Persists after 3 to 4 months of unsuccessful medical treatment for pathological gynecomastia.16 
-Pain or tenderness directly related to the breast tissue which has a clinically significant impact upon activities of daily living. 
-Clinical symptoms refractory to a trial of analgesics or anti-inflammatory agents. 
-For significant clinical manifestations when the excessive breast weight adversely affects the supporting structures of the shoulders, neck and trunk.  

You can find this rule in the Local Coverage Determination (LCD) - Cosmetic and Reconstructive Surgery (L39051) - Effective November 14, 2021.  

The rules say that the American Society of Plastic Surgeons' gynecomastia scale is as follows:  

1. Grade I: Small breast enlargement with localized button of tissue that is concentrated around the areola. 
2. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. 
3. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. 
4. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast  

You can find this rule in the Local Coverage Determination (LCD) - Cosmetic and Reconstructive Surgery (L39051) - Effective November 14, 2021.  

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.