REVIEW REQUEST FOR

Mastectomy for Gynecomastia

Provider Data Collection Tool Based on Clinical Guideline CG-SURG-88

Guideline Last Review Date: 07/26/2018 / Publish Date: 09/20/2018 / Provider Tool Effective Date: 09/20/2018
Individual’s Name: / Date of Birth:
Insurance Identification Number/HCID: / Individual’s Phone Number:
Ordering Provider Name & Specialty: / Provider ID Number:
Office Address:
Office Phone Number: / Office Fax Number:
Rendering Provider Name & Specialty: / Provider ID Number:
Office Address:
Office Phone Number: / Office Fax Number:
Date/Date Range of Service: / Place of Service: Home Inpatient
Outpatient Other:
Service Requested (CPT/HCPCS if known):
Diagnosis Code(s) (if known):

This clinical guideline based data collection tool is fora medical necessity review request for mastectomy performed for the treatment of gynecomastia. Gynecomastia is the unilateral or bilateral enlargement of male breast tissue attributed mainly to proliferation of ductular elements and not merely excessive breast tissue.

Pre-operative Photographs must be submitted. Only digital photography can accompany this tool if submitted electronically.

Please check all of the following that apply to the individual:

Request is for a mastectomy for gynecomastia in a male over age 18, or 18 months after the end of puberty

Request is for mastectomy using liposuction

Tissue to be removed is glandular breast tissue and not the result of obesity, adolescence, or reversible effects of a

drugtreatment which can be discontinued. (this would include drug-induced gynecomastia remaining unresolved

6 monthsafter the cessation of the causative drug therapy.) Specify drug

Appropriate diagnostic evaluation has been done for possible underlying etiology

Individual has pain or tenderness directly related to the breast tissue and is documented in the medical record

The pain has a clinically significant impact on activities of daily living and has been refractory to a trial of

analgesics or anti-inflammatory agents (for a reasonable time period adequate to assess therapeutic effects).

List the trial timeframe:

Pre-operative photographs are provided

Request for mastectomy is due to legitimate concern that a breast mass is present that may represent breast carcinoma.

(Mammography may be of value to determine the need for surgery in some instances).

***Provide the individual’s height:______AND weight: ______

Other (please list):

This request is being submitted:

Pre-Claim

Post– Claim (If checked, please attach the claim or indicate the claim number)

I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or it’s designees may perform a routine audit and request the medical documentation to verify the accuracy of the information reported on this form.

______

Name and Title of Provider or Provider Representative Completing Form and Attestation (Please Print)* Date

*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted

Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization management services on behalf of your health benefit plan or the administrator of your health benefit plan.

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