Clinical UM Guideline

This document addresses mastectomy when performed for the treatment of gynecomastia. Gynecomastia is the unilateral or bilateral enlargement of male breast tissue attributed mainly to proliferation of ductular elements and not merely excessive breast tissue. Mastectomy for gynecomastia is a surgical procedure performed to remove glandular breast tissue from a male with enlarged breasts.

Note: Please see the following related documents for additional information:

• CG-SURG-71 Reduction Mammaplasty
• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Note: This document does not address risk-reducing mastectomy. For criteria related to a risk-reducing mastectomy, refer to applicable guidelines used by the plan.

Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect.

Note: Not all benefit contracts include benefits for reconstructive services as defined by this document. Benefit language supersedes this document.

Note: For a high-level overview of this document, please see “Summary for Members and Families” below. 

Medically Necessary:

Mastectomy (including reconstruction if necessary) for gynecomastia in males is considered medically necessary when the following criteria are met:

1. Either 1 or 2 of the following:
   1. Over 18 years of age; or
   2. It has been 18 months or longer since the end of puberty;
      and
2. Tissue to be removed is glandular breast tissue; and
3. Tissue is not the result of obesity, adolescence, or reversible effects of a drug treatment which can be discontinued (this would include drug-induced gynecomastia remaining unresolved 6 months after cessation of the causative drug therapy); and
4. Appropriate diagnostic evaluation has been done for possible underlying etiology; and
5. Presence of pain or tenderness directly related to the breast tissue (documented in the medical record) which has a clinically significant impact upon activities of daily living; and
6. Pain has been refractory to a 3 month trial of analgesics or anti-inflammatory agents; and
7. Pre-operative photographs are provided.

Mastectomy for gynecomastia is considered medically necessary, regardless of age, when there is legitimate concern that a breast mass may represent breast carcinoma. Mammography may be of value to determine the need for surgery in some instances.

Reconstructive:

Mastectomy (including reconstruction if necessary) for gynecomastia in males is considered reconstructive when the following criteria are met:

1. The medical necessary criteria above are not met; and
2. Either 1 or 2 of the following:
   1. Over 18 years of age; or
   2. It has been 18 months or longer since the end of puberty;
      and
3. Mastectomy is used to treat drug-induced gynecomastia* that does not resolve by 6 months after the cessation of drug therapy.

* Examples of drugs associated with the occurrence of gynecomastia are listed in the Discussion/General Information section of this document (not an all-inclusive list).

Cosmetic and Not Medically Necessary:

Mastectomy for gynecomastia is considered cosmetic and not medically necessary when the reconstructive or medically necessary criteria above are not met.

Not Medically Necessary:

The use of liposuction to perform mastectomy for gynecomastia is considered not medically necessary.

This document describes clinical studies and expert recommendations, and explains whether mastectomy for gynecomastia is appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Mastectomy for gynecomastia is a surgery to remove enlarged male breast tissue caused by the growth of glandular (not fatty) tissue. This condition can happen in one or both breasts and is different from simple fat accumulation. The procedure may help when the tissue causes ongoing pain or raises concern for cancer. Most cases of gynecomastia in teens go away without surgery. Before considering surgery, doctors need to rule out other causes, such as side effects from medicines or medical conditions like hormone disorders. Liposuction, a method that removes fat, is not effective when the tissue is mostly glandular, and it may not prevent the condition from coming back.

What the Studies Show

Gynecomastia is common during puberty and usually goes away within 2 to 3 years without treatment. When it does not, or when it causes lasting pain or affects daily life, surgery may help. Research shows that surgery is generally safe and can relieve symptoms. Experts recommend more long-term studies to compare surgery types and understand which approach works best. Open surgery is often more effective for removing dense tissue, but it may cause more scarring. Minimally invasive options like liposuction may look better afterward but are not proven to work as well for removing dense tissue in the long-term. In many cases, surgery is not needed unless there is pain that does not get better with medicine or concern about cancer.

When is Mastectomy for Gynecomastia Clinically Appropriate?

Mastectomy (with or without reconstruction) may be appropriate in these situations:

• The person is over 18 years old, or it has been at least 18 months since puberty ended; and
• The tissue to be removed is glandular, not just fat; and
• The enlargement is not caused by obesity, puberty, or a medication that could be stopped; and
• Tests have ruled out other causes like disease or hormone problems; and
• The person has pain or tenderness in the breast tissue that affects daily activities; and
• The pain has not improved after 3 months of using pain relievers or anti-inflammatory medicines; and
• Pre-surgery photos are available to show the issue.

Surgery is also appropriate at any age when doctors suspect the breast lump might be cancer.

When is this not Clinically Appropriate?

Mastectomy is not considered appropriate when these criteria are not met. If the breast tissue is caused by fat, obesity, puberty, or medicines that can be stopped, and if there is no ongoing pain or concern for cancer, surgery is not recommended.

Using liposuction alone to remove glandular breast tissue is not appropriate. Studies show that it may not remove all of the tissue, which may cause the problem to return. Better studies are needed to know if newer methods like endoscopic surgery work as well over the long-term as traditional surgery.

(Return to Description)

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Excision:
When services are Medically Necessary:

When services may be Medically Necessary or Reconstructive when criteria are met:
For the procedure codes listed above, for the following diagnoses

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above when medically necessary or reconstructive criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

Liposuction:
When services are Not Medically Necessary:

Summary

Gynecomastia is a benign proliferation of glandular breast tissue that is distinct from lipomastia (pseudogynecomastia). The American Society of Andrology (ASA) and European Academy of Andrology (EAA) (Kanakis, 2019) guideline recommends an evaluation for underlying causes through history, examination, laboratory testing, and selective imaging. Mastectomy may be considered medically necessary when persistent glandular tissue causes functionally significant pain after puberty, reversible causes have been excluded, and a complete diagnostic work-up has been performed. Surgery is indicated at any age when malignancy cannot be ruled out. Traditional open excision reliably removes dense glandular tissue, while minimally invasive approaches may offer improved cosmetic outcomes but lack strong long-term evidence, and liposuction alone remains inadequate for true glandular disease in accordance with the American Society of Plastic Surgeons (ASPS) guidance (2015). Current studies suggest that multiple surgical techniques can achieve favorable short-term outcomes, but the evidence is limited by small sample sizes, heterogeneous methods, and brief follow-up. More rigorous, long-term comparative trials are needed to clarify which approaches provide the most durable and clinically meaningful results.

Description

Gynecomastia results from the growth of glandular breast tissue in males. This condition should not be confused with pseudogynecomastia, which is an enlargement of the male breast due to excess fat deposition. Gynecomastia is a transient phenomenon in up to 60 to 70% of pubescent boys and is considered a normal part of male adolescence. About 30 to 40% of adult men have been found to have gynecomastia. The incidence of gynecomastia peaks at three discrete times throughout a man’s life, during infancy, during puberty and in middle age and elderly men (Kanakis, 2019). Gynecomastia that is unilateral in post-adolescent age groups or that has a rapid onset is frequently associated with an underlying pathology. Medical conditions that can cause gynecomastia include chronic liver disease, Klinefelter’s syndrome (47XXY), adrenal tumors, pituitary tumors, testicular tumors, end-stage renal disease/dialysis, malnutrition and endocrine disorders (such as hyperthyroidism).

Prior to surgical intervention, a careful clinical evaluation is needed to rule out possible pathological etiologies. When a cause of the gynecomastia is determined and addressed appropriately, spontaneous resolution of the gynecomastia usually occurs over a short period. There can be psychosocial effects related to gynecomastia and psychotherapy may be recommended. Individuals with gynecomastia should be provided with reassurance about the self-limited nature of the condition, encouragement to participate in social and physical activities, and counseling on lifestyle modifications (Ladizinski, 2014).

The enlargement of male breast tissue may be unilateral or bilateral. When gynecomastia occurs in infancy or adolescence, it is usually benign. In adults, it has been suggested that approximately 45-50% of cases are associated with an underlying pathology. The most common pathologies associated with gynecomastia include systemic disease (for example, renal or hepatic disease, cancers), medications, obesity, and endocrinopathies (for example, hypogonadism or hyperthyroidism). In approximately 10% of cases, there is more than one etiology (Kanakis, 2019). Adolescent gynecomastia is considered a normal variation of puberty that rarely persists and typically spontaneously regresses within 18 to 24 months. If adolescents have surgical therapy before completion or at near completion of their puberty, the hormonal imbalance that caused the gynecomastia may cause recurrence (Cakan, 2007). Especially in children and youths, most cases of gynecomastia have no absolute indication for therapeutic intervention, as they are temporary and show a high number of spontaneous remissions (Fischer, 2014). Approximately 75% of cases resolve within 2 years of onset and 90% resolve within 3 years of onset (ASPS, 2015; Szar, 2023).

An initial diagnostic examination is performed to assess the type of involved tissue (for example, glandular or lipomastia) as well as for symptoms of breast cancer (such as hard, non-tender and or joining underlying structures) or testicular cancer. A subsequent, comprehensive examination may be needed in those individuals aged 18 or older. The ASA/EAA 2019 clinical practice guidelines suggest that the diagnostic evaluation include taking an extensive medical history, physical examination, laboratory testing and occasionally breast imaging (Kanakis, 2019).

The use of mastectomy for males under the age of 18 or for those who are not yet at least 18 months after the end of puberty (unless there is legitimate concern that a breast mass may represent breast carcinoma) is not considered an acceptable alternative to nonsurgical forms of treatment. A standard system used to describe the normal development of puberty and to determine if an adolescent is at or near completion of puberty is the Sexual Maturity Rating (SMR, Tanner Stage). The late stage of male puberty (Tanner stage 5) is evidenced by adult genitalia and adult type pubic hair. Completion of the Tanner stage 5 milestones typically signifies the end of puberty. Skeletal and muscle growth are also late events in male puberty. The cause of gynecomastia is frequently idiopathic, particularly in the adolescent age group (Kanakis, 2019; Waltho, 2017).

A retrospective review by Rosen and colleagues (2010) evaluated a consecutive series of adolescents with gynecomastia and compared surgical outcomes and demographics of obese and overweight to normal weighted individuals. A single institution database queried for male "breast" specimens from 1997-2008 identified 69 cases. Data extracted included body mass index (BMI) criteria, which demonstrated that 51% were obese, 16% overweight and 33% normal-weighted. Major complications (surgical hematoma requiring operative evacuation) occurred in 4 individuals (5.8%) and minor complications in 19 (27.5%). A total of 16 individuals required revision surgery. Potential etiologies other than obesity were found in 27%. Individuals with obesity required more extensive operations. Adolescents with obesity suffered greater psychological impact preoperatively but had no difference in satisfaction or complication rates, as compared to individuals of normal weights. The authors concluded that given their study results, obesity should not be used as an absolute contraindication to gynecomastia surgery. Study limitations included retrospective design of the study and a limited sample size.

Zavin and colleagues (2017) performed a large retrospective analysis comparing outcomes post gynecomastia (primarily cosmetic and elective) procedures in pediatric and adult populations. Data were extracted from the American College of Surgeons National Surgical Quality Improvement Program adult and pediatric databases for 1583 adult and 204 pediatric males. The adult population was considered overweight with a cohort BMI of 28.2 and BMI was not calculated for the pediatric population. However, a low proportion of preoperative comorbidities revealed a healthy population overall with rates of 4.9% in children and 6.4% in adults. Procedures in both groups were performed mostly on an outpatient basis. Low surgical and medical complication rates were observed within a 30-day postoperative period for both groups with rates of 3.9% in children and 1.9% in adults. Children and adolescents required increased mean operative times compared to adults (11.3 vs. 56.7 minutes). Study limitations reported by the authors included results may not be representative of every practice setting; an inability to differentiate between mastectomies, liposuction procedures or a combination of both; and short follow-up period of only 30 days.

A smaller retrospective study by Choi and colleagues (2017) reported short-term surgical outcomes of gynecomastia for 71 adolescents at a single Korean facility. Bilateral subcutaneous mastectomy with liposuction was performed for adolescents with a history of gynecomastia for over 3 years with psychological distress as a result. A total of 14 individuals (19.7%) experienced complications and 3 cases (4.2%) required revision. In all, 51 individuals (71.8%) were classified as having a glandular breast component. A majority of cases (70 individuals, 98.6%) self-reported satisfaction with the results. Study limitations reported by the authors included its retrospective nature and a short follow-up period of 6 months (with annual telephone interviews, thereafter).

The 2019 ADA/EAA clinical practice guidelines note:

Only a small proportion of patients with GM will need surgical treatment. The vast majority of patients either will experience spontaneous regression or will receive specific treatment that will relieve the underlying pathology.

However, gynecomastia, being a proliferative condition of the male breast, can occasionally lead to concern about the development of carcinomatous changes in the breast. In some cases, biopsy results do not lead to a clear distinction between non-cancerous and cancerous breast tissue. In such cases, mastectomy is indicated regardless of age to properly address those concerns.

Agents Associated with Drug-Induced Gynecomastia

Gynecomastia may be a side effect of certain drugs, including, but not limited to, estrogens, androgens, spironolactone, digitalis preparations, flutamide, ketoconazole, cimetidine, anabolic steroids, alcohol, amphetamines, and marijuana. Between 9.3% and 25% of reported cases of gynecomastia may be attributed to medications. Yang (2024) notes the following:

The mechanism of drug-induced gynecomastia varied depending on the specific medication. It may involve androgen antagonism, estrogen receptor activation, or hormone synthesis alteration.

Yang and associates (2024) conducted an analysis of the FDA Adverse Event Reporting System Database to identify the most common medications associated with gynecomastia. The most common category of medications associated with gynecomastia is nervous system medications. The following medications have been identified as potential causes of gynecomastia (Faridi, 2025; Yang, 2024):

Surgical Techniques

A variety of surgical techniques have been described as being used to perform mastectomy for gynecomastia, including direct excision, liposuction or a combination of both. Dao (2025) notes:

Traditionally, open excision has been considered the gold standard for its ability to thoroughly remove excess breast and adipose tissue, demonstrating high efficacy in treating gynecomastia. This method involves making a larger incision to directly excise the tissue, effectively reducing recurrence rates. However, the associated larger incisions can lead to prolonged recovery times and more pronounced scarring, which may adversely affect the patient’s appearance and mental health.

While the short-term benefits of endoscopic surgery are well-documented, including reduced operation times, lower complication rates, and expedited recovery, data regarding its long-term efficacy and recurrence rates remain limited. This gap has fueled ongoing debate within the medical community concerning the significant differences in long-term outcomes between these surgical methods. Specifically, understanding the long-term recurrence rates and patient satisfaction associated with endoscopic liposuction compared to traditional open excision is a key area of current research.

Diao (2025) conducted a prospective randomized study using a convenience sample of 140 men with gynecomastia to compare endoscopic lipolysis/liposuction with traditional open excision, finding that the endoscopic approach resulted in less postoperative pain, fewer complications, and higher satisfaction, with both groups demonstrating similar one-year recurrence of pain, discomfort, or tissue enlargement. However, the study did not report the type or amount of tissue removed, nor did it specify the clinical symptoms that constituted a “medical indication” for surgery or how many individuals underwent the procedure for pain, functional concerns, or cosmetic reasons. These omissions, combined with the single-center design, modest sample size, and limited follow-up, constrain interpretation of the findings, and longer-term, multicenter studies with clearer reporting of participant indications and tissue characteristics are needed to determine the comparative durability and appropriate use of each surgical technique.

Earlier studies comparing open excision and liposuction were subject to similar limitations. Petty (2010) retrospectively compared four surgical techniques in 227 individuals and reported that combining liposuction with an arthroscopic shaver produced the highest aesthetic scores, although complication rates and reoperation needs were similar across groups; the study’s retrospective design and small technique-specific cohorts limited its conclusions. Qutob (2010) evaluated vacuum-assisted biopsy device excision with liposuction in 36 men and reported high satisfaction with minimal need for reoperation, but the small, nonrandomized sample limits generalizability. Together, these studies suggest that while various minimally invasive and hybrid techniques show promise in improving aesthetic outcomes with acceptable complication rates, higher-quality, comparative trials are needed to determine the optimal surgical approach for gynecomastia.

Song and colleagues (2014) analyzed a Chinese experience of 402 males (436 breasts) treated with mastectomy and 331 males (386 breasts) treated with liposuction techniques for gynecomastia. Age range was 15 to 82 years (mean age, 29.1 years). The primary complaint was breast enlargement associated with pain with or without a palpable lump. A total of 330 (82%) complained of breast lump and lump with pain in the mastectomy group, and 204 (61%) complained of breast enlargement and enlargement with pain in the liposuction group (p<0.05). There was 1 case of Klinefelter’s syndrome, and another of gynecomastia resulting from hormonal therapy for prostate cancer. All excision specimens were submitted for routine histological analysis which showed pathologic diagnosis in the mastectomy cases (100%). Of those undergoing liposuction, 159 (41%) had acquired pathologic diagnosis through fine needle aspiration or core biopsy. Reoperation rates in the mastectomy and liposuction groups were 1.4% and 0.5%, respectively. Liposuction was performed if breast enlargement had been present for generally more than 12 months. However, true glandular hypertrophy required a surgical glandular tissue excision and subsequent histological examination. The authors concluded that surgical treatment of gynecomastia requires an individual approach, “depending on symptoms (lump or enlargement) and requirements of patients.”

Liposuction may be sufficient to remove predominantly fatty breast tissue (Waltho, 2017). While adult individuals with gynecomastia typically have predominantly fatty breast tissue, younger individuals commonly have higher amounts of dense glandular tissue which requires direct glandular excision rather than liposuction for removal (Nuzzi, 2018). The use of liposuction to remove glandular tissue as compared to standard surgical approaches has not been shown to produce comparable, long-term results. The incomplete excision of breast tissue could serve as a target for endogenous hormonal stimulation and result in a recurrence of the condition (Innocenti, 2017).

Gynecomastia: An excessive development of the male mammary glands, resulting in enlargement of the male breast, due mainly to ductal proliferation with periductal edema. Mild gynecomastia may occur in normal adolescence.

Mastectomy: The surgical removal of a breast.

Pseudogynecomastia (also known as lipomastia): Enlargement of the male breast due to excess fat deposition.

Sexual Maturity Rating (SMR, Tanner Stage): A commonly used measurement of sexual maturity in children, based upon the work of Tanner et al. (1962); SMR is based upon clinical findings from physical examination, as detailed below:

Classification of Sex Maturity States in Boys*

*From Tanner JM: Growth at Adolescence, 2nd ed. Oxford, England, Blackwell Scientific Publications, 1962. SMR, sexual maturity rating, and Marcell AV. Chapter 12- Adolescence. In: Kliegman RM, Behrman RE, Jenson HB, Stanson BF, Editors. Nelson Textbook of Pediatrics. 18th Ed. St. Louis, MO: WB. Saunders, Inc. 2007.

Peer Reviewed Publications:

1. Arca MJ, Caniano DA. Breast disorders in the adolescent patient. Adolesc Med Clin. 2004; 15(3):473-485.
2. Cakan N, Kamat D. Gynecomastia: evaluation and treatment recommendations for primary care providers. Clin Pediatr (Phila). 2007; 46(6):487-490.
3. Choi BS, Lee SR, Byun GY, et al. The characteristics and short-term surgical outcomes of adolescent gynecomastia. Aesthetic Plast Surg. 2017; 41(5):1011-1021.
4. Diao X, Wang M, Chen D, et al. A comparative study on the short-term and long-term efficacy of endoscopic lipolysis, liposuction, and traditional open excision in gynecomastia treatment. BMC Endocr Disord. 2025; 25(1):48.
5. Faridi A, Gerber B, Hartmann S. Diseases of the male breast: gynecomastia and breast cancer. Dtsch Arztebl Int. 2025; 122(15):406-411.
6. Fischer S, Hirsch T, Hirche C, et al. Surgical treatment of primary gynecomastia in children and adolescents. Pediatr Surg Int. 2014; 30(6):641-647.
7. Hammond DC. Surgical correction of gynecomastia. Plast Reconstr Surg. 2009; 124(1 Suppl):61e-68e.
8. Hammond DC, Arnold JF, Simon AM, Capraro PA. Combined use of ultrasonic liposuction with the pull-through technique for the treatment of gynecomastia. Plast Reconstr Surg. 2003; 112(3):891-895.
9. Hines SL, Tan W, Larson JM, et al. A practical approach to guide clinicians in the evaluation of male patients with breast masses. Geriatrics. 2008; 63(6):19-24.
10. Hodgson EL, Fruhstorfer BH, Malata CM. Ultrasonic liposuction in the treatment of gynecomastia. Plast Reconstr Surg. 2005; 116(2):646-653.
11. Innocenti A, Melita D, Mori F, et al. Management of gynecomastia in patients with different body types: considerations on 312 consecutive treated cases. Ann Plast Surg. 2017; 78(5):492-496.
12. Ladizinski B, Lee KC, Nutan FN, et al. Gynecomastia: etiologies, clinical presentations, diagnosis, and management. South Med J. 2014; 107(1):44-49.
13. Lanitis S, Starren E, Read J, et al. Surgical management of gynaecomastia: outcomes from our experience. Breast. 2008; 17(6):596-603.
14. McGrath MH, Schooler WG. Elective plastic surgical procedures in adolescence. Adolesc Med Clin. 2004; 15(3):487-502.
15. Mentz HA, Ruiz-Razura A, Newall G, et al. Correction of gynecomastia through a single puncture incision. Aesthetic Plast Surg. 2007; 31(3):244-249.
16. Nuzzi LC, Firriolo JM, Pike CM, et al. The effect of surgical treatment for gynecomastia on quality of life in adolescents. J Adolesc Health. 2018; 63(6):759-765.
17. Petty PM, Solomon M, Buchel EW, Tran NV. Gynecomastia: evolving paradigm of management and comparison of techniques. Plast Reconstr Surg. 2010; 125(5):1301-1308.
18. Qutob O, Elahi B, Garimella V, et al. Minimally invasive excision of gynaecomastia--a novel and effective surgical technique. Ann R Coll Surg Engl. 2010; 92(3):198-200.
19. Rohrich RJ, Ha RY, Kenkel JM, et al. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg. 2003; 111(2):909-923.
20. Rosen H, et al. Adolescent gynecomastia: not only an obesity issue. Ann Plast Surg. 2010; 64(5):688-690.
21. Song YN, Wang YB, Huang R, et al. Surgical treatment of gynecomastia: mastectomy compared to liposuction technique. Ann Plast Surg. 2014; 73(3):275-278.
22. Szar M, Dendy CB, Hillenbrand K. Breast conditions (disorders) in children. Pediatr Rev. 2023; 44(11):665-667.
23. Waltho D, Hatchell A, Thoma A. Gynecomastia classification for surgical management: a systematic review and novel classification system. Plast Reconstr Surg. 2017; 139(3):638e-648e.
24. Yang X, Zheng X, Zhang M, et al. Drug-induced gynecomastia: data mining and analysis of the FDA adverse event reporting system database. Clin Epidemiol. 2024; 16:617-630.
25.  Zavlin D, Jubbal KT, Friedman JD, Echo A. Complications and outcomes after gynecomastia surgery: analysis of 204 pediatric and 1583 adult cases from a national multi-center database. Aesthetic Plast Surg. 2017; 41(4):761-767.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American College of Radiology (ACR). Expert Panel on Breast Imaging; Niell BL, Lourenco AP, Moy L, et al. ACR appropriateness criteria^® evaluation of the symptomatic male breast. J Am Coll Radiol. 2018; 15(11S):S313-S320.
2. American Society of Plastic Surgeons (ASPS). ASPS recommended insurance coverage criteria for third-party payers. Gynecomastia Surgery. Reaffirmed June 2015. Available at: https://www.plasticsurgery.org/for-medical-professionals/health-policy/recommended-insurance-coverage-criteria. Accessed on December 17, 2025.
3. Hampl SE, Hassink SG, Skinner AC, et al. Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. Pediatrics. 2023; 151(2):e2022060640.
4. Kanakis GA, Nordkap L, Bang AK, et al. EAA clinical practice guidelines-gynecomastia evaluation and management. Andrology. 2019; 7(6):778-793.
5. Marcell AV. Chapter 12- Adolescence. In: Kliegman RM, Behrman RE, Jenson HB, Stanson BF, Editors. Nelson textbook of pediatrics. 18th Ed. St. Louis, MO: WB. Saunders, Inc. 2007.
6. Tanner JM. Growth at Adolescence, 2nd ed. Oxford, England, Blackwell Scientific Publications, 1962. SMR, sexual maturity rating.
7. Townsend. Sabiston textbook of surgery, 16th edition. W. B. Saunders Company, 2001:559, 1567.

1. Endocrine Society. Gynecomastia. January 24, 2022. Available at: https://www.endocrine.org/patient-engagement/endocrine-library/gynecomastia. Accessed on December 17, 2025.
2. Pediatric Endocrine Society/American Academy of Pediatrics. Pubertal Gynecomastia. Publication Date June 17, 2020. Available at: https://pedsendo.org/patient-resource/pubertal-gynecomastia/. Accessed on December 17, 2025.
3. U.S. National Library of Medicine. MedlinePlus. Breast enlargement in males. Review Date 10/1/2024. Available at: https://medlineplus.gov/ency/article/003165.htm. Accessed on December 17, 2025.

Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. Clinical UM guidelines are used when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether or not to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the back of the member's card.