Gynecomastia Treatment Coverage Determination Guideline (Effective 02/01/2012) Proprietary Information of UnitedHealthcare. Copyright 2012 United HealthCare Services, Inc.

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COVERAGE DETERMINATION GUIDELINE

Gynecomastia Treatment

COVERAGE RATIONALE INSTRUCTIONS FOR USE This Coverage Determination Guideline provides assistance in interpreting certain standard UnitedHealthcare benefit plans. When deciding coverage, the enrollee specific document must be referenced. The terms of an enrollee’s document (e.g., Certificates of Coverage (COCs), Schedules of Benefits (SOBs), or Summary Plan Descriptions (SPDs),and Medicaid State Contracts) may differ greatly from the standard benefit plans upon which this guideline is based. In the event of a conflict, the enrollee's specific benefit document supersedes these guidelines. All reviewers must first identify enrollee eligibility, any federal or state regulatory requirements and the plan benefit coverage prior to use of this guideline. Other coverage determination guidelines and medical policies may apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its coverage determination guidelines and medical policies as necessary. This Coverage Determination Guideline does not constitute medical advice.

UnitedHealthcare may also use tools developed by third parties, such as the Milliman Care Guidelines®, to assist us in administering health benefits. The Milliman Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.

Guideline Number: CR-A-008 Effective Date: February 1, 2012

Applicable Products:

UHIC Community and State MAHP (MDIPA and

Optimum Choice Inc.) Neighborhood Health

Partnership Related Policies: None Related Coverage Determination Guidelines: Cosmetic and Reconstructive Procedures Panniculectomy & Body Contouring Procedures Revision Grid for Gynecomastia

Table of Contents COVERAGE RATIONALE........................................... DEFINITIONS……………………………………………. APPLICABLE CODES................................................. REFERENCES............................................................ HISTORY/REVISION INFORMATION........................

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Gynecomastia Treatment Coverage Determination Guideline (Effective 02/01/2012) Proprietary Information of UnitedHealthcare. Copyright 2012 United HealthCare Services, Inc.

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COVERAGE RATIONALE Plan Document Language Before using this guideline, please check enrollee’s specific plan document and any federal or state mandates, if applicable. Indications for Coverage See Coverage Limitations and Exclusions below Coverage Limitations and Exclusions

Some states require benefit coverage for services that UnitedHealthcare considers cosmetic procedures, such as repair of external congenital anomalies in the absence of a functional impairment. Please refer to enrollee’s plan specific documents.

Standard plans specifically exclude treatment of benign Gynecomastia. This includes mastectomy or suction lipectomy of breast tissue

For ASO plans with SPD language other than fully-insured Generic COC language:

Please refer to the enrollee’s plan specific SPD to determine if the plan has an exclusion for benign gynecomastia treatment. When the SPD has an exclusion for benign gynecomastia, the treatment or surgery is not eligible for coverage. When an ASO plan does not have a specific exclusion for treatment of benign gynecomastia: Most medical and surgical treatments for benign gynecomastia are considered cosmetic and are under the cosmetic exclusion in the plan. Medical treatments and surgery to alter a perceived abnormal appearance, or for psychological reasons, are considered cosmetic and are not covered. The fact that a Covered Person may suffer psychological consequences or socially avoidant behavior as a result of benign gynecomastia does not classify surgery (or other procedures done to relieve such consequences or behavior) as a reconstructive procedure. A clinical review is required to determine if the treatment or surgery is cosmetic or meets reconstructive criteria. I. Required Documentation: The decision regarding whether the requested procedure will be covered as reconstructive or excluded from coverage as cosmetic will require review of the following clinical information/documentation, and such other documentation as may be reasonably requested:

1. Contemporaneous physician office notes with the history of the medical condition(s) requiring treatment or surgical intervention. This documentation must include ALL of the following;

a. A well-defined physical and/or physiological abnormality resulting in a medical condition that has required or requires treatment ; AND

b. The physical and/or physiological abnormality has resulted in a functional deficit; AND

Gynecomastia Treatment Coverage Determination Guideline (Effective 02/01/2012) Proprietary Information of UnitedHealthcare. Copyright 2012 United HealthCare Services, Inc.

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c. The functional deficit is recurrent or persistent in nature

2. Appropriate clinical studies/tests addressing the physical and/or physiological abnormality that confirm its presence and the degree to which it is causing impairment

3. Frontal and lateral high-quality color photographs of the torso. The date taken, the service reference identification number (obtained at time of notification) or patient’s name and ID number must be documented on the photograph(s). The enrollee’s identification must be documented on the photograph using either name or health plan identification number

4. History of prior medication use, e.g. testosterone for low testosterone level

5. Treatment plan that must include the proposed procedures and the expected outcome for the improvement of functional impairment.

II. Criteria for a Coverage Determination to be Reconstructive:

When complete, we will be review the information supplied above to render a coverage determination. A requested procedure will be deemed reconstructive and therefore covered when:

Male patient under age 18:

History of prescribed medications and screening of non-prescription and/or recreational drugs or substances that have a known side effect of gynecomastia should be pursued. If a functional impairment is present as defined below, a clinical review is required to determine if it meets reconstructive criteria.

Additional Information: In most cases breast enlargement and/or benign gynecomastia spontaneously resolves by age 18 making treatment unnecessary. Gynecomastia during puberty is not uncommon and in 90% of cases regresses within 3 years of onset.

Male patient age 18 and up:

Mastectomy is considered reconstructive when ALL of the following criteria are present:

A. Discontinuation of medications, nutritional supplements, and non-prescription

medications or substances that have a known side effect of Gynecomastia or breast enlargement and the breast size did not regress after discontinuation of use as appropriate.

B. Gynecomastia or breast enlargement with moderate to severe chest pain that is

causing a functional impairment defined below. The inability to participate in athletic events, sports or social activities is not considered to be a functional or physiological impairment.

C. Results of tests that have been done to rule out certain diseases or other

causes of Gynecomastia: examples include but are not limited to:

1. Blood tests, e.g. hormone levels estrogen, testosterone 2. Breast ultrasound 3. Liver and kidney function studies/enzymes 4. Mammogram

Gynecomastia Treatment Coverage Determination Guideline (Effective 02/01/2012) Proprietary Information of UnitedHealthcare. Copyright 2012 United HealthCare Services, Inc.

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D. Glandular breast tissue is the primary cause of Gynecomastia as opposed to fatty deposits and is documented on physical exam and/or mammography.

DEFINITIONS

Benign Gynecomastia: the development of abnormally large breasts in males. It is related to the excess growth of breast tissue (glandular), rather than excess fat tissue.

Congenital Anomaly: a physical developmental defect that is present at birth, and is identified within the first twelve months of birth. (2001 FI Generic COC) A physical developmental defect that is present at the time of birth, and that is identified within the first twelve months of birth. (2007 through 2011 Generic COC) Congenital Anomaly (California Only): a physical developmental defect that is present at birth Cosmetic Procedures: Cosmetic Procedures are excluded from coverage. Procedures that correct an anatomical Congenital Anomaly without improving or restoring physiologic function are considered Cosmetic Procedures. The fact that a Covered Person may suffer psychological consequences or socially avoidant behavior as a result of an Injury, Sickness or Congenital Anomaly does not classify surgery or other procedures done to relieve such consequences or behavior as a reconstructive procedure. (2001 FI - 2011 Generic COC) Procedures or services that change or improve appearance without significantly improving physiological function, as determined by UHC (2007 through 2011 Generic COC). Cosmetic Procedures (California Only): procedures or services are performed to alter or reshape normal structures of the body in order to improve the Covered Person's appearance Functional/Physical Impairment: A physical/functional or physiological impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas: physical and motor tasks; independent movement; performing basic life functions. Gynecomastia (fully-insured 2001 through 2011 COC): Abnormal breast enlargement in males High Quality Photograph: ideally a high-quality print should be in color have at least 200 pixels per inch. It must be detailed enough to show the patient’s anatomy that is described in the physician’s office notes If submitted as a hard copy, the image must be on photographic paper. Reconstructive Procedures: Surgery or other procedures which are associated with an Injury, Sickness or Congenital Anomaly, performed when a physical impairment exists and when the primary purpose of the procedure is to improve or restore physiologic functions. The fact that physical appearance may change or improve as a result of a reconstructive procedure does not classify such surgery as a Cosmetic Procedure when a physical impairment exists, and the surgery restores or improves function. (2001 Generic COC) Reconstructive procedures when the primary purpose of the procedure is either to treat a medical condition or to improve or restore physiologic function. Reconstructive procedures include surgery or other procedures which are associated with an Injury, Sickness or Congenital Anomaly. The primary result of the procedure is not a changed or improved physical appearance.

Gynecomastia Treatment Coverage Determination Guideline (Effective 02/01/2012) Proprietary Information of UnitedHealthcare. Copyright 2012 United HealthCare Services, Inc.

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Procedures that correct an anatomical Congenital Anomaly without improving or restoring physiologic function are considered Cosmetic Procedures. The fact that a Covered Person may suffer psychological consequences or socially avoidant behavior as a result of an Injury, Sickness or Congenital Anomaly does not classify surgery (or other procedures done to relieve such consequences or behavior) as a reconstructive procedure. (2007- 2011 Generic COC) Reconstructive Procedures (California Only): Reconstructive procedures to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. Reconstructive procedures include surgery or other procedures which are associated with an Injury, Sickness or Congenital Anomaly. The primary result of the procedure is not a changed or improved physical appearance for cosmetic purposes only, but rather to improve function and/or to create a normal appearance, to the extent possible. Covered Health Services include dental or orthodontic services that are an integral part of reconstructive surgery for cleft palate procedures. Sickness - physical illness, disease or Pregnancy. The term Sickness as used in this Certificate does not include mental illness or substance abuse, regardless of the cause or origin of the mental illness or substance abuse. APPLICABLE CODES

The Current Procedural Terminology (CPT®

) codes and HCPCS codes listed in this guideline are for reference purposes only. Listing of a service code in this guideline does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the enrollee specific benefit document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Other policies and coverage determination guidelines may apply.

CPT®

is a registered trademark of the American Medical Association.

Limited to specific procedure codes?

YES NO

CPT® Procedure Code Description

19300 MASTECTOMY FOR GYNECOMASTIA Coding for suction lipectomy is addressed on the Panniculectomy and Body Contouring Procedures Coverage Determination Guideline.

Limited to specific diagnosis codes?

YES NO

Limited to place of

service (POS)? YES NO

Limited to specific

provider type? YES NO

Limited to specific

revenue codes? YES NO

Gynecomastia Treatment Coverage Determination Guideline (Effective 02/01/2012) Proprietary Information of UnitedHealthcare. Copyright 2012 United HealthCare Services, Inc.

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REFERENCES 1. NIH Medline Plus http://www.nlm.nih.gov/medlineplus/ency/article/003165.htm.Narula

HS, Carlson HE. Gynecomastia. Endocrinol Metab Clin North Am. 2007/36:497-519. Ali O, Donohue PA. Gynecomastia. In: Kliegman RM, Stanton BF, Geme JW, Schor NF, Behrman RE, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 579.

2. Stavros Diamantopoulos and Yong Bao.Gynecomastia and Premature Thelarche: A Guide for Practitioners. Pediatr. Rev. 2007;28;e57-e68. Available @ http://pedsinreview.aappublications.org/cgi/content/full/28/9/e57

GUIDELINE HISTORY/REVISION INFORMATION

Date Action/Description 12/01/2010 Original Effective Date. 02/01/2012 Revision of ASO Indications for Coverage, documentation and review

criteria; title changed; added CA definitions for Cosmetic Procedures and Reconstructive Procedures. Updated footer removing confidential. Link to revision grid and FAQ. Post 11/1/2011 for 02/01/2012 effective date. Added California Only statement pg. 3

12/01/2012 New Template Format Updated the Applicable Products table on Page 1.