Gynecomastia and Insurance.

[gynebegone2]

A user posted this information in a reply to a somewhat obscure topic heading.  I thought I would repost it in hopes that more individuals read it.


After battling my insurance company since 2003 I got my excision portion approved (the liposuction was not that much more) in December 2007.   I cited the gynecomastia case from New York in which a gyencomastia sufferer sued his insurance company and won.  Here are the generically relevant passages of my insurance company appeal I filed.  Because gynecomastia is painful you must also include numerous ER visits to document gynecomastia pain and functional impairement and the insurance company will realize it is cheaper to pay a few thousand on the surgery than tens of thousands in ER costs:

Courts have ruled that gynecomastia surgery is medically necessary.

Certainly instructive is Steven S. v. GHI 2004 NY Slip Op 24464, 6 Misc. 3d 213, 787 N.Y.S.2d 828, 2004 N.Y. Misc. LEXIS 2327, affirmed on appeal in Schulman v. Group Health Incorporated,  2007 NY Slip Op 2804, 39 A.D.3d 223, 833 N.Y.S.2d 62, 2007 N.Y. App. Div. LEXIS 4127 (Supreme Court of New York, Appellate Division 2007) wherein the court ruled that gynecomastia surgery, even without pain or considering the serious risk of cancer was neither elective nor cosmetic.  It held that gynecomastia surgery was medically necessary treatment to eliminate impaired functioning and that “gynecomastia was an objective, tangible, and unusual source of turmoil, more akin to a clubfoot or cleft palate than to a large nose, heavy acne, or diminutive breasts on an adolescent female. The latter conditions, while objective and tangible, are relatively common and often lead to elective and cosmetic treatments.”

Cancer risk makes gynecomastia surgery medically necessary.

The breast is an epicenter of cancerous activity in the body.  The genesis of many a cancerous death starts by suspicious lumps in the breast of both sexes.  The procedure is medically necessary because the gynecomastia tissue removed in the procedure would be sent to a pathology lab for analysis for cancer and pre-cancerous cells.  Women merely worried about possible cancer risk haven taken to prophylactic breast removal to thwart cancer in the future.  Therefore, all men with gynecomastia are entitled as of right to have medically necessary gynecomastia surgery to prevent cancer.  See Ductal carcinoma in situ in a 16-year old adolescent boy with gynecomastia: a case report, J Pediatr Surg. 2005 Aug;40(:1349-53; Gynecomastia, neurofibromatosis and breast cancer, Breast. 2004 Feb;13(1):77-9; Breast enlargement in young men not always gynecomastia: breast cancer in a 22-year old man, ANZ J Surg. 2005 Oct;75(10):914-6;  Bilateral atypical ductal hyperplasia, an incidental finding in gynecomastia – case report and literature review, Breast. 2005 Aug;14(4):317-21;  Male gynecomastia and risk for malignant tumors – a cohort study, BMC Cancer. 2002 Oct 16;2:26.

The standard of care for male patients with suspicious breast masses is to remove all the festering painful fibrofattyductal breast tissue and send it to the pathology lab.  Unlike females, males do not need to preserve breast tissue for social or functional purposes and gynecomastia surgery is medically necessary and akin to tonsillectomy, appendectomy, and wisdom teeth removal, in that it is standard surgical practice to remove unnecessary painful and diseased body parts for the good of the patient.  

Gynecomastia pain makes the surgery medically necessary

Clearly, gynecomastia is a painful condition.  In fact, the medical helpline referred [insert your name] to the emergency room to get on pain medicine in order to document the pain which would make the removal of the offending tissue medically necessary.  There is clear support in the medical literature that removal of gynecomastia tissue ameliorates gynecomastia pain.  See Gynecomastia due to hormone therapy for advanced prostate cancer: a report of ten surgically treated cases and a review of treatment options.  Tumori. 2004 Jul-Aug;90(4):410-5.  Again that the condition is deteriorating only serves to validate that the surgery is medically necessary back when first requested on [insert first requested date].  [insert insurance carrier's name]'s Tuskegee-like policy of letting a covered insured languish for five years is punitive, outrageous, malicious, bad faith denial of coverage, and civilly actionable.  

Denial of requested surgery is violates federal law and is unconstitutional as applied

Even assuming, in arguendo, that the procedure was cosmetic, the coverage policy manual covers a myriad of cosmetic breast surgeries for women such as providing or removing breast implants as described in the section relating to female breasts on [insert page and section numbers].  Incidentally, the manual implies the notion that female breast tissue is often removed for medically necessary purposes.  Most cogently, because cosmetic breast surgery is provided for women, it must also be provided for men who want to remove allegedly cosmetic gynecomastia tissue and this must be so in order to avoid running afoul of the Civil Rights Act and the United States Constitution’s Fourteenth Amendment Equal Protection Clause.  Although the right to the surgical procedure at issue is not a fundamental right, the discrimination based on the sex of a citizen requires that a court nonetheless apply the strict scrutiny standard.  Therefore, disparate provision of two citizens of different genders the benefit of cosmetic breast surgery amounts to unconstitutional discrimination no different than and subject to the same constitutional scrutiny as voting and employment discrimination based on sex.  However, a court need not necessarily analyze this issue because the surgery is medically necessary and not cosmetic.

This seems to be an excellent and researched source to prepare an appeal to your insurance company.

NOTE: Some of this information may be provider specific, and you should ensure it applies to your situation before submitting.

m90291 if you are still frequenting the forum, it would be great to have you ellaborate a bit on your successful claim.

[captklenk]

I was approved for gynecomastia surgery also. Anthem Blue Cross PPO. I did have to meet certain requirements.

A) tissue must be glandular and not simply fat (obesity as a cause will disqualify)
B) gynecomastia must be causing physical or emotional PAIN
C) medications have proven unable to resolve the gynecomastia or pain caused by it

It is advisable to go through the normal steps so that a medical record is established.

I first went to my family doctor, then to a radiologist for an ultrasound, and finally to a surgeon within the Anthem network.
The first surgeon I went to told me that there was NO WAY insurance would pay for the operation. Needless to say I was
very discouraged. Of course he was WRONG. I persevered and with the help of my family doctor I finally obtained insurance approval.
I did have to submit a lot of requested information including photos, and a written diagnosis from my doctor.

I waited almost 20 years for this operation and must say it is a great weight off my shoulders.

[tttdone]

I also got insurance to cover my surgery. But since insurance is covering it, the surgery will be done by a "general cosmetic / reconstructive surgeon." but he says he does about 2 gyne surgeries a month and he will be doing both exision and lipo.
I am insured with Kaiser Permanente.. Kaiser is the hospital AND the insurance company.
I will be getting the surgery done August 20, 2008. (exactly one week from today). i am so ready to get this over with...
good luck to all of you

[captklenk]

Anthem allowed me to schedule surgery with a Plastic Surgeon. I've seen some guys chests butchered by general surgeons, so do your research if the surgeon is not board certified as a Plastic Surgeon. After all, whats the use of getting surgery only to look worse than before.

[blueturtle80085]

captklenk,

I'm very intrigued by your success. I too have an Anthem Blue Cross PPO carrier through my work and I've yet to dig deep enough to see what their policy is on gyno and what the success rate is for subscribers who have tried to get them to cover the surgery but it's good to note that you've had some success.

What were the exact steps that you took? You said general doctor, radiologist and then surgeon?

Do you think you would have had less success had your family doctor not been so helpful?

I'm only 23 years old but I've had gyno since I was 17/18. I've gotten very discouraged every time I see a doctor because they assume my gyno was from steroids when I played college football, however this is not the case, I've had  gyno since I was much younger and I've never experimented with anabolic steroids or hormones. I think it might be from heavy drinking and anxiety medication I've been on ever since I was 16/17.

Either way what would you say the best plan of attack is? Did you contact the insurance company directly or did your doctor / surgeon do that for you?

Thanks for any help or advice you could give. It makes me smile a little to see that a least a few people have had some success.

[captklenk]

captklenk,

I'm very intrigued by your success. I too have an Anthem Blue Cross PPO carrier through my work and I've yet to dig deep enough to see what their policy is on gyno and what the success rate is for subscribers who have tried to get them to cover the surgery but it's good to note that you've had some success.

What were the exact steps that you took? You said general doctor, radiologist and then surgeon?

Do you think you would have had less success had your family doctor not been so helpful?

I'm only 23 years old but I've had gyno since I was 17/18. I've gotten very discouraged every time I see a doctor because they assume my gyno was from steroids when I played college football, however this is not the case, I've had  gyno since I was much younger and I've never experimented with anabolic steroids or hormones. I think it might be from heavy drinking and anxiety medication I've been on ever since I was 16/17.

Either way what would you say the best plan of attack is? Did you contact the insurance company directly or did your doctor / surgeon do that for you?

Thanks for any help or advice you could give. It makes me smile a little to see that a least a few people have had some success.

I had to have my family doctor submit the info to Anthem because the Plastic Surgeon's office was unwilling to do the footwork......

I went to see my family doctor regarding the gyno. He then referred me to a radiologist for the ultrasound, and once this established it to be gynecomastia my doctor referred me to a surgeon. The surgeons office submitted the claim to insurance, however when Anthem requested more info (as outlined previously) to determine if it was "medically necessary", the surgeons office told me that I had to submit the info myself. (they simply wanted me to pay out of pocket and really didn't care if insurance approval was obtained) As I said, my family doctor at this point took over. His office was willing to gather and submit the info Anthem requested, including photos etc...A real credit to him and his office for being so helpful. A doctors recommendation will greatly influence the nurses at Anthem in regards to their final decision. The bottom line is be persistent and be patient. The entire process from beginning to end took a few MONTHS. Also, if you speak to the nurses at Anthem, remember to be friendly at all times as the old adage holds true "You can catch more flies with honey than vinegar" I hope it works out for you my friend.

[headheldhigh01]

that was a great news item. 

now if only i HAD insurance