appealing insurance denial for gynecomastia surgery

[sonrisagrande]

My health insurance is with Kaiser Permanente.
I have tried to gain approval for surgery to correct my bilateral gynecomastia condition, but Kaiser Permanente has denied the surgery because they claim is it solely a cosmetic surgery.

I am an athlete and run competitively.  When I run long distances (~10-26.2 miles) my shirt rubs against my large breasts and causes my nipples to bleed, sometimes quite a bit.  I have covered my nipples with different types of tape to prevent the bleeding, but the tape sometimes falls off due to perspiration.  These are the grounds on which I have appealed to Kaiser Permanente to get approval for the surgery.  I'm 5"11 and weigh 178 pounds (I have larger than normal legs from cycling long distances).

At this point, my appeal has been completely denied by Kaiser Permanente, and I've taken the appeal to the State Corporation Commission, Bureau of Insurance for my state (Virginia).  Today I went to a doctor who is not affiliated with Kaiser Permanente, and he strongly recommends that I have the surgery done.  He is writing a letter of recommendation which will be forwarded to the State Corporation Commission, Bureau of Insurance.  

Does anyone have an idea if this case stands any chance of being approved in this particular situation, and reasons why?  I've almost reached my limit of patience!

[DrPensler]

Twenty years ago my patients would virtually all be approved for surgery by their insurance.Today in my experience the approval rate is under 1%. A few  years back a physician for Blue Cross called me re a case and said I just want to tell you three things 1) I used to practice as a pediatric surgeon and although I did not treat gynecomastia I am very familiar with it 2) I personally think it should be covered 3) The company has a policy where it is not covered under any circumstances.
Jay Pensler,MD

[jojo82]

My health insurance is with Kaiser Permanente.
I have tried to gain approval for surgery to correct my bilateral gynecomastia condition, but Kaiser Permanente has denied the surgery because they claim is it solely a cosmetic surgery.

I am an athlete and run competitively.  When I run long distances (~10-26.2 miles) my shirt rubs against my large breasts and causes my nipples to bleed, sometimes quite a bit.  I have covered my nipples with different types of tape to prevent the bleeding, but the tape sometimes falls off due to perspiration.  These are the grounds on which I have appealed to Kaiser Permanente to get approval for the surgery.  I'm 5"11 and weigh 178 pounds (I have larger than normal legs from cycling long distances).

At this point, my appeal has been completely denied by Kaiser Permanente, and I've taken the appeal to the State Corporation Commission, Bureau of Insurance for my state (Virginia).  Today I went to a doctor who is not affiliated with Kaiser Permanente, and he strongly recommends that I have the surgery done.  He is writing a letter of recommendation which will be forwarded to the State Corporation Commission, Bureau of Insurance.  

Does anyone have an idea if this case stands any chance of being approved in this particular situation, and reasons why?  I've almost reached my limit of patience!

Very little chance. Check your policy documents. Kaiser is a large insurer, and most large insurers explicitly state that they do not cover gynecomastia surgery.

[jojo82]

I will post this here for anyone googling. You MUST REVIEW YOUR POLICY DOCUMENTS before visiting your doctor. All major insurers have policy documents for providers that explicitly outline how, when, and to what degree certain procedures will be covered. All of that information can be found on most insurer's websites under the provider information section. If you review those documents before you go to the doctor, you will know how to "tailor" your condition for maximum results. For example, United Health Care has extremely restrictive requirements that make it all but impossible to get approved, whereas CIGNA has a fairly liberal policy that would allow almost anyone here to get approved. In either event, the information on what your doctor/surgeon will be looking for is available for your viewing. Even with United Health Care, it's possible to "tailor" your condition to meet most requirements; it may not succeed, but you must give yourself a fighting chance with these companies.

Back to the topic at hand: review your policy documents to see how and when your insurer will cover your condition, and then appeal.

[jojo82]

Twenty years ago my patients would virtually all be approved for surgery by their insurance.Today in my experience the approval rate is under 1%. A few  years back a physician for Blue Cross called me re a case and said I just want to tell you three things 1) I used to practice as a pediatric surgeon and although I did not treat gynecomastia I am very familiar with it 2) I personally think it should be covered 3) The company has a policy where it is not covered under any circumstances.
Jay Pensler,MD

That 1% rate is probably true of insurance companies approving certain plastic surgeons to conduct the procedure. Insurance companies (esp. restrictive HMOs) will approve gyne surgery under defined circumstances, but it will almost always be done in a hospital by a surgeon pre-approved by the insurer. For gyne sufferers who read their policy docs ahead of time, the success rate is far above 1%.

[morpheus11]

thanks some really good info jojo, thanks for posting that. I'm going to try and get my insurance company to cover it, if not, then I guess it's out of pocket for me.

[NEVERAGAIN]

I told my insurance company that my the gland made my chest very sore, which it sort of did.  They paid for it.