Payer PolicyActive
CG-SURG-88 Mastectomy for Gynecomastia
ANTHEM-CG-SURG-88
Anthem
Effective: October 1, 2025
Updated: December 30, 2025
Policy Summary
This policy addresses mastectomy for male gynecomastia (including reconstruction if needed). It is covered as medically necessary when the individual is either over age 18 or at least 18 months past the end of puberty, and the tissue to be removed is glandular breast tissue; procedures not meeting these criteria are considered cosmetic and not covered. Use of liposuction to perform mastectomy for gynecomastia is not medically necessary.
Coverage Criteria Preview
Key requirements from the full policy
"Mastectomy (including reconstruction if necessary) for gynecomastia in males is consideredmedically necessarywhen the following criteria are met:"
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