Hey guys what does this mean?

[bluemrgreen]

Guys I just got insurance through my job and I think im covered for gyno but Im not sure

Guys I understand everything expect for number 6? What does it mean? that i have to be sick to get the surgery??

Do i have to go to a doctor so he can tell my insurance or can a surgeon make a claim?


When Mastectomy for Gynecomastia is covered
Mastectomy for the condition of gynecomastia is covered when ALL of the following conditions are met:
1. Male is over 18 years of age (Male gynecomastia is not uncommon in adolescent males, and generally
resolves without treatment.) or male is over 17 years of age with significant breast tissue present for
over two years AND
2. Excess breast tissue is glandular and not fatty tissue. (This is confirmed by clinical exam, mammogram
and/or tissue pathology.) AND
3. Other causes of gynecomastia have been ruled out, including reversible drug treatments (When drugs
can be discontinued). AND
4. Excessive breast development is not due to non-covered therapies or illicit drugs, e.g., anabolic steroids
or marijuana AND
5. If gynecomastia is caused by obesity (BMI>30), it is documented to have failed to respond to conservative
measures which must include participation in a clinically supervised, comprehensive weight loss
and exercise program for at least 6 months, AND
6. The patient has documented and significant medical symptoms not resolved by more conservative treatments.

[jojo82]

Be very careful before you proceed. You are one of the few sufferers who has bothered to check policy documents/coverage guidelines BEFORE seeing a doctor. It's generally advisable to document physical pain when you are asked (routine question from the nurse/doctor).

One thing I am concerned about is how your insurance company defines "mastectomy." Please research this term in your policy docs.  If you are on a restrictive HMO and if you're approved, you may end up going to a surgeon not experienced in Gynecomastia surgery. Also be mindful of that possibility. Research approved surgeons thoroughly.

As far as point #6, it sounds like they are wanting to see documented proof that some other medication/procedure short of surgery did not work. The way it is worded, it sounds like a generic catchall phrase that the insurance company can use to weasel their way out of paying.

Also, I'm not sure if this passage came from the insurance company's guidelines or your particular group policy. Remember that if you have a group policy, the wording in your schedule of benefits supersedes any documentation/policies on the insurer's website and corporate policies.

Regardless of the type of insurance, it's always wise to go through your primary care physician (and if you're on an HMO, it's likely a requirement). There is always the possibility that the cause of enlarged breasts is something more dangerous than just breast tissue.

[bluemrgreen]

thanks i really appreciate your quick informative response. i really dont care about this insurance thing, the only people I would feel confident with my chest are Dr. Jacobs, Dr. Pope or Dr Bermant. If its not one of those its not gonna happen. So if your saying that they will most likely give me a list to choose from, im not interested in this insurance coverage. Ive had gyno since like i was 11 or 12 and 2 of my brothers and my father has it, so i think its genetic or something lol.

[Dr. Elliot Jacobs]

jojo82 is correct -- your #6 is a "get out of jail card" for the insurance company.

You can bolster your claim for #6 in that there are no currently available conservative treatments known -- other than trying to wait it out and hoping that it disappears spontaneously.  You can also document any pain or discomfort by discussing these possible symptoms with your doctor.  You can also add emotional distress(if indeed it is present) by consulting with a mental health profession and obtaining a letter from that person attesting to the emotional component of the problem.

And yet, when it is all said and done, the company has the ultimate discretion as to whether they want to reimburse you / pay the surgeon or not.  And there is no-one to appeal to except a higher authority at the same insurance company.  Kinda makes you want to love those insurance companies, doesn't it?

Dr Jacobs

[hatemymoobs]

I just got off the phone with my insurance provider and was told surgery was considered cosmetic and generally wouldn't be covered. However, she did say to have the doctor send in some kind of letter stating why this is a medical condition or how it is affecting me medically, not just cosmetically.

I wonder if they would sympathize with someone suffering anxiety, depression, social anxiety, low self esteem, breast/nipple tenderness, and potentially future back problems from slouching over to have the shirt hang over them to hide them... Oh yea, low sex drive due to self consciousness which results in marriage tension, missing valuable time with my kid- going in the pool, running around playing soccer because it is uncomfortable.

The thing is they will say most of that is psychological. They don't say psychological issues are cosmetic because they cover treatment for depression, anxiety and other illnesses- so I don't see how they wouldn't consider this a treatment for not only an irregular male chest, but also a solution to mental hardship.

[hatemymoobs]

I see cosmetic/plastic surgery as things like boob jobs (when they already have boobs) or nose jobs, face lifts, Botox, etc.
Gynecomastia is not the same in my eyes. It's correcting an issue that is a medical condition.

Can gynecomastia increase chances of breast cancer? If so- maybe that can be used as well. My aunt had breast cancer to it could be in the family... Anything to get these insurance companies to cough up, even some of the cost!

[Dr. Elliot Jacobs]

Agree with you.  But bottom line, they will use any excuse not to pay for your surgery -- saying "it's all in your head."

When I am able to get a real person on the line at the insurance company, I ask the rep (usually a female) to look at the photos I had sent to them and ask if that were their son, wouldn't they want something done about it?  100% say yes.....but the company says no.

Dr Jacobs

[Dr. Elliot Jacobs]

Can gynecomastia increase chances of breast cancer?

No, gynecomastia does not predispose anyone to breast cancer.  But male breast cancer does exist -- usually in much older men.

Dr Jacobs

[hatemymoobs]

That's too bad.
Dr Jacobs have you ever had a patients insurance company pay full or even a portion of the cost?

I'm not sure if I understand your answer about breast cancer.
I know gyne won't cause cancer, but I'm wondering if men with gynecomastia are at more risk than men without gynecomastia.

If the chances for normal men are say 1 in 1,000. Are the chances say maybe 1 in 500 if you have gyne?
I've read the answer is yes, but who knows how good information on the internet is...

[Dr. Elliot Jacobs]

Dr Jacobs have you ever had a patients insurance company pay full or even a portion of the cost?

I have had some insurance companies pay some but never all of my fee.  Remember, they have their own fee schedule for payment (if they pay at all) and then they will only pay a percent of that fee. That fee schedule is proprietary -- they never share that schedule with the outside world.  Reimbursement is completely random and arbitrary.

I'm not sure if I understand your answer about breast cancer.
I know gyne won't cause cancer, but I'm wondering if men with gynecomastia are at more risk than men without gynecomastia.

To clarify: men with gynecomastia are not at any greater risk of developing male breast cancer.  However, male breast cancer does exist -- it comprises about 1% of all breast cancers.  It is usually in older men and starts on one side -- not both.  Any unexplained, one sided breast enlargement in an older man, any nipple discharge (bloody or otherwise), any skin changes, etc, should be examined by either a gyne surgeon or a breast surgeon ASAP.

Dr Jacobs