CG-SURG-88 Mastectomy for Gynecomastia

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.

"Mastectomy (including reconstruction if necessary) for gynecomastia in males is consideredmedically necessarywhen the following criteria are met:"

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