Reduction Mammoplasty and Gynecomastia Surgery

This policy covers reduction mammoplasty and surgical treatment of gynecomastia (including adolescent grades per Appendix C and gigantomastia) when medically necessary for symptomatic macromastia or persistent/pathologic gynecomastia meeting the policy’s detailed clinical criteria. Key requirements/limitations include age and developmental criteria (≥18 years, or <18 with Tanner stage V and ≥6 months no breast growth), documented symptoms affecting activities of daily living, failure of conservative measures, a negative mammogram within 1 year when indicated, minimum planned resection weight per the Schnur Sliding Scale (cases below the 22nd percentile require medical director review), and exclusion of cosmetic or physiologic/expectantly managed cases (gigantomastia of pregnancy only when delivery is not imminent).

"Reduction mammoplasty is medically necessary when the policy criteria in sections A or B are met (section A: macromastia or gigantomastia meeting all listed subcriteria)."