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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 4
Section 5.7
Issue Date:  May 18, 1994
Authority:  32 CFR 199.4
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
19300, 19304, 19318
2.1  Pathological gynecomastia is an abnormal enlargement of the male mammary glands. Some causes of pathological gynecomastia are testicular or pituitary tumors, some syndromes of male hypogonadism, cirrhosis of the liver, administration of estrogens for prostatic carcinoma, and therapy with steroidal compounds.
2.2  Physiological (pubertal) gynecomastia occurs in teenage boys, usually between the ages of 13-15. In more than 90% of these boys, the condition resolves within a year. Gynecomastia persisting beyond one year is severe and is usually associated with pain in the breast from distension and fibrous tissue stroma.
Benefits may be cost-shared for medically necessary medical, diagnostic, and surgical treatment.
Note:  Coverage criteria for surgical interventions may include, but is not limited to: severe gynecomastia (enlargement has not resolved after one year); fibrous tissue stroma exists; or breast pain.
Surgical treatment performed purely for psychological reasons.
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