Endocrine/metabolic/nutritional
Surgical Services (All)

Diagnosis: Gynecomastia
Treatment: Removal of Excess Tissue in the Breast Area
The insurer denied the Removal of Excess Tissue in the Breast Area. The health plan's determination is upheld.

This male has bilateral gynecomastia. He has not had any regression over at least two years. He denies any tenderness. He suffers from low self-esteem and embarrassment due to his breast size. Mastectomies for gynecomastia are planned.

The Removal of Excess Tissue in the Breast Area (Gynecomastia) is not medically necessary for this patient. The patient is likely to derive emotional benefit from the surgery, but his physiologic health will not be improved. The records in this case do not provide any evidence of a concern regarding breast cancer. The procedure will primarily improve appearance and self-esteem and therefore is cosmetic and not medically necessary. Observation, reassurance and use of analgesics as needed are standard management approaches for this condition. The patient is likely to derive emotional benefit from the surgery, but his physiologic health will not be improved.