Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgery to remove tissue from the breasts.Arya and colleagues state that true gynecomastia refers to enlarged glandular tissue rather than deposition of fat tissue. The enlargement of a breast due to deposition of fat in the breast area is known as pseudogynecomastia. They state that the aims of surgery are to eliminate painful breast tissue and to restore the patient's chest to an acceptable cosmetic shape. The most commonly used technique is subcutaneous mastectomy,  which involves direct resection of the glandular tissue using a periareolar or transareolar approach, with or without liposuction.Bellini and colleagues state that in pseudogynecomastia, there is an increased development of the fatty component in the male breast region. In true gynecomastia, however, there is an increase in volume of the male breast gland with a dense fibrous and vascular stroma, which makes suction more difficult. The gynecomastia liposuction treatment is usually associated with a resection under direct vision of the glandular tissue through a periareolar or transareolar incision.According to the American Society of Plastic Surgeons (ASPS), excision of gynecomastia is recommended for adults when breast biopsy is indicated because malignancy is suspected, when unilateral or bilateral grade III or IV gynecomastia is present, or when pain and discomfort are present due to the distention and tightness from a hypertrophied breast. For these purposes, the ASPS utilizes a gynecomastia scale adapted from the McKinney and Simon, Hoffman and Kohn scales. Grade III gynecomastia is present when there is moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present. Grade IV gynecomastia is present when there is marked breast enlargement with skin redundancy and feminization of the breast.This patient has lost 114 pounds and has residual breast fullness with significant skin laxity. His chest appearance is consistent with Grade III gynecomastia. There is no report of a palpable firm disc of glandular tissue under the nipple areolar complex to identify glandular hypertrophy as compared with pseudogynecomastia from residual fatty fullness. The diagnosis of glandular gynecomastia is not confirmed with mammography, and pathological causes of gynecomastia have not been ruled out by hormonal testing. However, given that the patient reports significant pain and tenderness, the requested service is medically indicated. Under these circumstances, surgery to remove tissue from the breasts is 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; or (2) to create a normal appearance, to the extent possible. In this case, the patient reports pain and tenderness over the chest and breast areas, especially with activity. The records note a diagnosis of bilateral gynecomastia, with painful glandular tissue, an abnormal structure of the body. The proposed surgery is for the relief of pain, which constitutes an improvement in function. Accordingly, the requested surgery to remove tissue from the breasts is reconstructive in nature for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition and is reconstructive in nature. Therefore, the Health Plans denial should be 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.