Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral mastectomy and liposuction procedure (CPT 19300 and 15877). Arya and colleagues state that, True gynecomastia refers to enlarged glandular tissue rather than deposition of fat tissue. Enlargement of breast due to deposition of fat in the breast area is known as pseudogynecomastia. The authors noted that, The aims of surgery are: (a) To eliminate painful breast tissue. (b) To restore the patients chest to acceptable cosmetic shape. The most commonly used technique is subcutaneous mastectomy that involves direct resection of the glandular tissue using a peri-areolar or trans-areolar approach, with or without liposuction. Per the American Society of Plastic Surgeons (ASPS), the requested bilateral mastectomy and liposuction procedure are not medically necessary. The records document that malignancy is not suspected. Physical examination revealed bilateral significant gynecomastia with subareolar glandular hypertrophy as well as an adipose component. The reports appear to be consistent with Grade III gynecomastia plus pseudogynecomastia. The patient denies any pain or other discomfort associated with gynecomastia, and his breast enlargement has been stable since his early 20s. The patient reports persistent pain and discomfort around his chest and areolar area that radiates into his arms with weakness. He also reports that the chest area becomes tender and sensitive to touch. Based on these findings, the patient has chest enlargement Grade III from a combination of gynecomastia and pseudogynecomastia. Hormonal testing is normal. The description of pain radiating into the arms with a connected weakness is not consistent with pain and discomfort due to the distention and tightness from the hypertrophied breast. Based on the medical information received for review, the requested bilateral mastectomy and liposuction procedure (CPT 19300 and 15877) are not medically necessary to treat the patients medical condition.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. Gynecomastia is an abnormal structure of the body caused by a developmental abnormality. Per Arya and colleagues, surgery is recommended over medical treatment when the patient has symptoms of gynecomastia for more than two years. The authors noted that, The aims of surgery are: (a) To eliminate painful breast tissue. (b) To restore the patients chest to acceptable cosmetic shape. This patient complains of persistent pain and discomfort around his chest and areolar area that radiates into his arms with weakness. He also reports that his symptoms are limiting his activities and certain exercises. Imaging and FNA are consistent with gynecomastia. Garcia states that, There are numerous surgical approaches for the correction of gynecomastia reported in the literature. In the past 20 years, several techniques involving liposuction in combination with glandular resection through minimal, well-concealed incisions have become popular due to their consistently good aesthetic outcomes and a lack of postoperative surgical stigmata. A distinction needs to be made, however, as to whether the liposuction is being used as the primary modality for treatment of the gynecomastia or whether the liposuction is being used for additional contouring after gynecomastia resection. According to the American Society of Plastic Surgeons (ASPS), although liposuction may be appropriate for contouring of the chest after gynecomastia excision, it is not supported as a separate procedure for treatment of this patients gynecomastia. Thus, the requested bilateral mastectomy (CPT 19300) is supported as reconstructive in nature to improve the patients level of function and eliminate painful breast tissue. Based on the California reconstructive surgery statute, the requested bilateral mastectomy (CPT 19300) is reconstructive in nature to treat the patients medical condition, while the requested liposuction procedure (CPT 15877) is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that a portion of the requested surgery is medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. 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.