Current through September 24, 2024
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.
Miss. Code Ann. §
43-13-121
