23 Miss. Code. R. 203-4.16

Current through December 10, 2024

Rule 23-203-4.16 - Male Gynecomastia

A. Medicaid covers mastectomy, including reconstruction if necessary, for gynecomastia when considered medically necessary when the following criteria are met:

1. The tissue removed is glandular breast tissue and 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 six (6) months after cessation of the causative drug therapy),

2. Appropriate diagnostic evaluation has been done for possible underlying etiology,

3. Pain or tenderness directly related to the breast tissue has been refractory to a trial of analgesics, anti-inflammatory agents, etc., for a time period adequate to assess therapeutic effects,

4. The excessive breast tissue development is not caused by non-covered therapies or illicit drug usage such as marijuana, anabolic steroids, etc.,

5. The beneficiary has a physician documented history of two (2) years or more of gynecomastia that has been refractory to conservative treatments,

6. Unclothed preoperative photographs from the chin to the waist, including standing frontal and side views with arms straight down at sides, and

7. The beneficiary is over eighteen (18) years of age, or eighteen (18) months after the end of puberty.

B. Medicaid does not consider mastectomy for gynecomastia to be medically necessary under certain circumstances. Examples of such circumstances Medicaid does not cover include, but are not limited to, the following:

1. The beneficiary has pseudogynecomastia, which is excess adipose tissue in the male breast, but with no increase in glandular tissue,

2. The procedure is for cosmetic purposes, or

3. Only liposuction is used as the surgical procedure.

C. Medical record documentation of medical necessity must include all of the following:

1. A summary of the medical history and last physical exam, including the information specified in Part 203, Chapter 4 Rule 4.15.A,

2. All prior treatments used to manage the beneficiary's medical symptoms,

3. Results from any diagnostic tests pertinent to the diagnosis taken within the last six months,

4. Photo documentation confirming breast hypertrophy taken within the last six months with the beneficiary's name and date on each photo,

5. A surgical treatment plan that outlines the amount of tissue to be removed from each breast and the prognosis for improvement of clinical signs and symptoms pertinent to the diagnosis, and

6. Other pertinent clinical information that Medicaid may request.

D. Providers must maintain proper and complete documentation to verify the services provided. The provider has full responsibility for maintaining documentation to justify the services provided.

23 Miss. Code. R. 203-4.16

Miss. Code Ann. § 43-13-121