Does Medicare Cover Gynecomastia Surgery?

Gynecomastia is a condition characterized by the enlargement of male breast tissue. Understanding how Medicare covers surgical correction is a common concern. Medicare coverage for gynecomastia surgery is not automatically granted and depends on specific criteria. The program distinguishes between procedures performed for cosmetic enhancement and those deemed medically necessary to address health issues.

Eligibility Criteria for Medicare Coverage of Gynecomastia Surgery

Medicare coverage for gynecomastia surgery hinges on establishing medical necessity, differentiating it from purely cosmetic procedures. Medically necessary procedures are those required to diagnose or treat an illness, injury, or medical condition. Conversely, cosmetic surgeries, performed solely to improve appearance, are generally not covered by Medicare.

For gynecomastia surgery to be considered medically necessary, specific criteria must be met and thoroughly documented. This includes persistent, significant pain or discomfort caused by the enlarged breast tissue. Functional impairment, such as interference with daily activities or exercise, can also support a claim of medical necessity. The condition should have persisted for two years or more and not responded to conservative treatments like medication, weight loss, or observation.

Documentation is crucial to substantiate the medical necessity of the procedure. Detailed medical records from the treating physician are required, outlining the symptoms, their duration, and the impact on the patient’s life. Evidence of conservative treatments attempted and their ineffectiveness must also be provided. Diagnostic test results, such as imaging to rule out other underlying conditions, are often necessary. In cases where significant psychological distress is a justification, evaluations or notes from a mental health professional can be important supporting evidence.

Medicare Parts and Your Financial Responsibility

Medically necessary surgical procedures, including gynecomastia surgery, are primarily covered under Medicare Part B, which is medical insurance. This part of Medicare helps pay for doctor’s services, outpatient care, and certain medical services and supplies. If the surgery requires an inpatient hospital stay, Medicare Part A, hospital insurance, would cover the facility costs.

Under Medicare Part B, beneficiaries are responsible for out-of-pocket costs. After meeting the annual Part B deductible ($257 in 2025), Medicare pays 80% of the approved amount for covered services. The remaining 20% is the patient’s coinsurance. For inpatient hospital stays covered by Part A, the deductible in 2025 is $1,676 per benefit period. Daily coinsurance amounts apply for longer hospital stays, such as $419 per day for days 61-90 and $838 per day for lifetime reserve days in 2025.

Supplemental insurance options can help manage these out-of-pocket expenses. Medigap policies, sold by private companies, are designed to cover some of the costs that Original Medicare (Parts A and B) does not, such as deductibles, coinsurance, and copayments. Medicare Advantage (Part C) plans, offered by private insurers, bundle Part A and Part B coverage, often including additional benefits. It is important to confirm that the surgeon and facility accept Medicare assignment to avoid higher out-of-pocket costs.

The Process for Obtaining Coverage and Appeals

Initiating the process for Medicare coverage of gynecomastia surgery begins with a consultation with a physician experienced in these cases. The physician will assess the condition and gather the necessary medical documentation to support the claim of medical necessity. This comprehensive preparation ensures that all criteria are met before formal requests are submitted.

Some Medicare Advantage plans, and occasionally Original Medicare for specific procedures, may require prior authorization or pre-approval before the surgery can proceed. This involves submitting the collected medical evidence to Medicare or the private plan for review. If prior authorization is required and not obtained, the patient may be responsible for the full cost of the procedure. Providers typically submit claims to Medicare after services are rendered.

After a claim is processed, Medicare sends a Medicare Summary Notice (MSN), or a private plan sends an Explanation of Benefits (EOB), detailing the decision. If coverage for the surgery is denied, beneficiaries have the right to appeal the decision. The first level of appeal is a Redetermination, which involves a review of the claim by a Medicare Administrative Contractor (MAC). This request must be filed within 120 days of the initial denial.

Should the Redetermination not resolve the issue, the next step is a Reconsideration by a Qualified Independent Contractor (QIC). This second-level appeal must be filed within 180 days of receiving the Redetermination notice. If the denial persists, an Administrative Law Judge (ALJ) hearing is the third level of appeal. An ALJ hearing requires a minimum amount in controversy, which is $190 for requests filed on or after January 1, 2025. Further appeal levels include the Medicare Appeals Council and Federal Court review.