Important Insurance Question. Please help!?!

[blueturtle80085]

Hi, I recently asked my insurance provider (Anthem Blue Cross/Shield) about my policy and their stance towards gynecomastia and got the following response:

Dear Mr. ######

Thank you for contacting Anthem Blue Cross and Blue Shield.

You currently have benefits available for a medically necessary Mastectomy for Gynecomastia. There is a medical policy which lists criterion that must be met in order for your insurance to cover such a service. I have attached a copy of the policy to this email, which you may want to review with your physician to see if you would be eligible for such a service.

Under this policy, covered services provided by an in-network provider will be covered at 90% of the maximum allowance until the $700 coinsurance amount has been satisfied.

Once the total deductible and coinsurance out of pocket amount has been met, Anthem will process claims at 100% of the maximum allowable benefit for the remainder of the calendar year.

If there is a different service that you are referring to, please let me know and I would be happy to research that further for you.


Is this a good sign? Anyone else get the same type of response from Blue Cross?

Thanks

[Paa_Paw]

The term "Medically Necessary" Gives you a possible way to get the surgery covered. The same term gives the insurance company a way to avoid covering the cost.

It may be a good idea to ask your primary care Doctor for a referral to a Psychologist. What you would want to establish is that the Gynecomastia is causing you to suffer psychologically and thereby establish a medical necessity. If the condition is causing you to be depressed, have low self esteem and be socially isolated etc. and the psychologist will provide a letter to that effect you might get the surgery covered. Otherwise, the Insurance Company might claim the the surgery would be for purely cosmetic reasons and refuse payment.

In the absence of any pathological condition, this may be the only way to establish any degree of necessity.

The Psychologist would probably be covered without question by the insurance company but possibly not so you have a bit more homework to do before proceeding

[PSC0002]

"Mastectomy" freaks me out.  Is there any way you can find out if gland excision with lipo is considered a "mastectomy" under their definition? 

[blueturtle80085]

*Follow-up*

this is the cutup regarding gynecomastia from my insurance policy (ANTHEM Blue Cross/Blue Shield).

Please read and comment:


Mastectomy for Gynecomastia

Medically Necessary:
Mastectomy (including reconstruction if necessary) for gynecomastia in a male over age 18, or 18 months after the end of puberty, is considered medically necessary if the tissue removed is glandular breast tissue and not the result of obesity, adolescence, or reversible effects of a drug treatment which can be discontinued. Conditions which may be associated with gynecomastia include, but are not limited to:
1. Documented androgen deficiency
2. Chronic liver disease that causes decreased androgen availability
3. Klinefelter's syndrome (47XYY)
4. Adrenal tumors that cause androgen deficiency or increased secretion of estrogen
5. Brain tumors that cause androgen deficiency
6. Testicular tumors causing androgen deficiency or tumor secretion of estrogen
7. Endocrine disorders-e.g. hyperthyroidism

Mastectomy (including reconstruction if necessary) for gynecomastia in a male over age 18, or 18 months after the end of puberty, is considered medically necessary for drug-induced gynecomastia that does not resolve after 6 months after cessation of drug therapy. Some drugs that are associated with the occurrence of gynecomastia include, but are not limited to, the following: Estrogens, androgens, spironolactone, digitalis preparations, flutamide, ketoconazole, and cimetidine. Drugs of abuse that can be associated with gynecomastia include use of steroids, alcohol and marijuana. Pre-operative photographs may be requested.

Mastectomy for gynecomastia is considered medically necessary, regardless of patient age, when there is legitimate concern that a breast mass may represent breast carcinoma.

Not medically necessary:
Mastectomy for gynecomastia is considered not medically necessary when the above criteria are not met.

Investigational:
The use of liposuction to perform mastectomy for gynecomastia is considered investigational.


Gynecomastia
Gynecomastia has been linked to several disorders affecting the endocrine system as well as to side effects of some drugs. Frequently, treating the underlying condition such as removal of a tumor or altering medications will resolve gynecomastia. Such conservative measures should be attempted prior to any surgical approach to gynecomastia. The medical literature on gynecomastia indicates that gynecomastia is due to the stimulated growth of glandular breast tissue and does not significantly affect the disposition of fatty tissue. Therefore, mastectomy for
gynecomastia must focus on the removal of glandular tissue underlying the condition. The use of liposuction as a method of mastectomy for gynecomastia has not been proven to remove glandular tissue and is not considered an acceptable alternative to standard surgical approaches to gynecomastia. Gynecomastia, being a proliferative condition of the male breast, can occasionally lead to concern about the development of carcinomatous changes in the breast. In some cases, biopsy results do not lead to a clear distinction between non-cancerous and cancerous breast tissue. In such cases, mastectomy is indicated regardless of patient age to properly address those concerns.

True gynecomastia is a result of a variety of conditions causing a hormone imbalance and results in the growth of glandular breast tissue. This condition should not be confused with pseudo-gynecomastia, which is an enlargement of the breast due to fat deposition. According to the American Society of Plastic Surgeons, gynecomastia is usually a transient phenomenon in up to 60% to 70% of pubescent boys and is considered a normal part of male adolescence. The peak incidence occurs at 14 to 14 1/2 years, and spontaneously resolves 1 to 2 years after onset. However, about 30% to 40% of adult men have been found to have gynecomastia. Frequently the cause is unknown and not due to tumors of the endocrine system or drug side-effects. True
gynecomastia, which has an unknown cause, is usually long-standing and medical and laboratory investigation is frequently unnecessary to determine a cause. In such cases, surgery is the only alternative to leaving the condition unaltered. Alternatively, gynecomastia that has a rapid onset can frequently be associated with an underlying cause. In such cases doctors are able to determine the cause of the gynecomastia and address it appropriately, which allows it to self-resolve over a short period of time.

D. Mastectomy for gynecomastia; male
When services are medically necessary:
CPT 19140 Mastectomy for gynecomastia
ICD-9 Procedure 85.20 Excision or destruction of breast tissue, not otherwise specified
85.41, 85.42 Simple mastectomy
ICD-9 Diagnosis 175.0, 175.9 Malignant neoplasm male breast
198.81 Breast
233.0 Breast (excludes Roget’s disease and Skin of breast)

When services may be Medically Necessary when criteria are met:
For the procedure codes listed above, all other diagnoses, when Medical policy criteria are met

When services are not Medically Necessary:
For the procedure codes listed above, when Medical policy criteria are not met

When services are Investigational:
CPT 15877 Suction assisted lipectomy; trunk (When used to report reduction
mammaplasty performed by liposuction method)

Calculation: BSA=square root of {(height in inches x weight in pounds) / 3131}
e.g. Height-5.5" (65inches) x Weight -160lbs =10,400/3131= √3.32= 1.82 BSA
To calculate body surface area see:
http://www.intmed.mcw.edu/clincalc/body.html
NOTE:
• Pictures (front and lateral views) of the trunk including shoulders, breasts must be submitted
• Medical records from the PCP documenting the above will be required for adolescents and may be required in other patients. The Physician Verification Form is not intended as a substitute for, nor does it preclude, the Prior Authorization/Pre-Certification requirements set forth in the member's contract benefit plan. In addition to this form, as evidenced above, Anthem Blue Cross and Blue Shield may, in its sole discretion, request the complete medical record, or any part thereof during the evaluation for determination of medically necessity.


I do attest that the above is true and accurate to the best of my knowledge
Physician Name (Print)______________________ Physician Signature:____________________ Date:________



*END*


The part that worries me a little is when it talks about gyno that is a result from obesity or puberty. I don't feel like mine is either as I didn't experience symptoms till I was in college and done growing and although I weigh 240lbs I'm 6'6" and have a fairly athletic build as I've played sports my whole life. I guess I just need to know how they define "obese".

Please comment and share thoughts... I'm hopeful but will still have to feel the process out as I'm desperately searching for a way to have to procedure, as I've only fiananced 1.5k as we speak.


Do you think if the surgery is ok'd... I'd have to use the surgeon that they suggest/supply?

Thanks again

[PSC0002]

*Follow-up*
 I guess I just need to know how they define "obese".

They tell you how they define obese, using the calculation you included in your message.  There's tons of BMI calculators out there that will help you figure it out.  Whether or not they are accurate to you is another question.  I am of similiar size and weight - 6'3' - 230 lbs, and I've seen calculators that tell me I am obese.  Yeah, so I've drank a few too many beers over the years, but I don't see myself as being morbidly obese.  (yes I realize that obese and morbidly obese are different things)  But what I'm getting at is I'm tall, broad shouldered, and medium muscular - using height and weight doesn't really work that well - I'm a BIG guy, not obese.  (in my opinion)

I have Blue Cross/Blue Shield.  I looked into trying to get it covered, but gave up.  I figured it would be denied because I was a fairly new customer, had been overweight as a child, and probably by their definition "obese".  I have a low opinion of Insurance companies, right up there with AIG executives and used car salesmen.  I gave up.  I might have been able to get it covered, at least partly, but I doubt it. 

If you haven't already - go see a PS of your choice.  Mine had many payment plans and such available through outside companies.  I chose to pay for mine via Mr. Mastercard because I have a low rate and my house is on the market in a fairly decent local sales climate. (if anybody wants a house, send me a message - lol)  It would be nice if I could have had it paid for, but it wasn't worth the hassle to me.

[Paa_Paw]

The term "Mastectomy" would scare me as well. Performing a mastectomy on Gynecomastia is somewhat like using a sledge hammer to tap in a small brad.