Surgical removal of breast tissue, such as mastectomy or liposuction, as a treatment of gynecomastia, is considered investigational due to the lack of functional impairment. Exceptions can be made when medical appropriateness criteria are met. See policy guidelines.
Mastectomy for gynecomastia may be considered medically necessary if all of the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Mastectomy for gynecomastia for the treatment of the following conditions, including but not limited to, breast enlargement from obesity, breast enlargement from drug treatment that can be discontinued, or removal of fatty tissue alone is considered cosmetic.
