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MA11.110a, Surgery for Gynecomastia
Effective date
Not stated in the notice
Identified
Jun 19, 2026
Summary
This is a reissue of MA11.110a with no substantive changes to coverage criteria for gynecomastia surgery. The policy continues to require Grade III or IV severity, 3-4 months of persistence, failed conservative treatment, and documented pain or functional impairment for coverage. Independence Blue Cross Medicare Advantage is reaffirming existing medical necessity standards per their annual review process.
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What to do
Action · 4 steps
01No immediate action required.
02This is a reissue with no changes to existing coverage criteria, billing codes, or documentation requirements.
03Billing team should verify current encounter forms and prior authorization templates already reflect the existing medical necessity criteria (Grade III-IV gynecomastia, 3-4 month persistence, failed conservative treatment, documented pain/functional impairment, failed analgesic/anti-inflammatory trials).
04No workflow updates needed unless they were not previously compliant with this policy.
Codes mentioned
19300N62
Original notice
MA11.110a, Surgery for Gynecomastia
medpolicy.ibx.com · Always check the source before changing claims.
Related changes
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