Chapter 4
Section 5.7
Gynecomastia
Issue Date: May 18, 1994
Copyright: CPT
only © 2006 American Medical Association (or such other date of
publication of CPT).
All Rights Reserved.
Revision:
1.0 CPT
PROCEDURE CODES
19300, 19304, 19318
2.0 DESCRIPTION
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.
3.0 POLICY
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.
4.0 EXCLUSION
Surgical treatment performed purely for psychological
reasons.
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