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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 with no substantive changes to MA11.110a. The policy maintains existing coverage criteria for gynecomastia surgery under Independence Blue Cross Medicare Advantage plans, requiring Grade III-IV disease, failed conservative treatment, and documented functional impairment. No billing codes, coverage rules, or documentation requirements have changed since the original 12/19/2022 effective date.
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What to do
Action · 4 steps
01No immediate action required.
02This is an administrative reissue with no substantive policy changes.
03Billing teams should verify their current systems already reflect the existing coverage criteria: Grade III-IV gynecomastia only, prior failed medical management (3-4 months), documented functional impairment affecting ADLs or supporting structures, and failure of analgesic/anti-inflammatory trial.
04If not already implemented, ensure prior authorization is in place for CPT 19300 claims and that documentation checklists include color photographs, letter of medical necessity, and medical records of prior treatment attempts.
Codes mentioned
19300N62
Original notice
MA11.110a, Surgery for Gynecomastia
medpolicy.ibx.com · Always check the source before changing claims.
Related changes
See all Independence Blue Cross changes →MA11.110a, Surgery for GynecomastiaLowNo effective date · Medical Policy11.08.12i, Surgery for GynecomastiaLowNo effective date · Medical Policy11.08.12i, Surgery for GynecomastiaLowNo effective date · Medical PolicyMA11.069f, Reduction MammoplastyMediumEffective Jun 3, 2024 · Claims & BillingBrowse every Independence Blue Cross change in the policy list