Mastectomy as a Treatment of Gynecomastia

By August 31, 2026: (1) Billing team must implement prior authorization requirement in billing software for CPT 19300 (Mastectomy for gynecomastia). (2) Providers must be trained to document all required elements before submitting claims: gynecomastia grade (II or higher), tissue type (glandular/fibrotic, not adipose), duration of condition, evaluation of reversible causes (medications reviewed, medical conditions assessed), documentation of breast pain/tenderness, and age-specific persistence duration (12+ months for adults age 19+; 24+ months plus Tanner Stage IV for adolescents 16-18). (3) Update encounter templates and prior auth request forms to include checklist of required documentation. (4) Front desk staff must alert patients that procedures not meeting medical necessity criteria may be classified as cosmetic and subject to patient financial responsibility. (5) Implement claim denial protocols for submissions lacking required documentation or not meeting criteria.