Insurance denial-help please

[maddogforq]

My husband had a mastectomy for Gynecomastia in May and we are currently appealing for the second time to our insurance company to pay the claim.  They have denied the claim stating that he had the surgery without previously being treated using more conservative measures including being treated with antibiotics??  First, I have read a lot about Gynecomactia and have not read any where about treatment with antibiotics.  Is this a valid treatment?
(The doctor that suggested the antibotics upon review was an Urologist.  Do they normally treat patients with gyne?) Second, my husband is not over weight, does not and has not used steriods nor does he take any medications that might contribute to this condition.  His onset was quite rapid, lump from the size of a pea to the size of a quarter in a couple of months and he experienced a lot of pain to the point that he couldn't hug people on that side of his body and had to hold himself when he went up and down stairs.  Our insurance is BCBS.  Has anyone been successful winning an appeal with them?  We had three medical professionals tell us that his choices were to "live with the pain" or to have the surgery.  What other conservative choices might there be that BC is referring to?

[nothingworse]

Well, I can help you somewhat. BCBS might have been referring to medical treatments such as tamoxfine, andractim, etc. But, those really aren't treatments. I have the same problem as your husband with pain and I took 3 different forms of medicine which didn't help a bit with anything. They really don't work. Although some will argue they due I have yet to see a person on this board say they do. The best thing I have heard yet is like a 10-20% reduction in gland size. But, the medicine isn't going to help the pain. And stating that your husband is fit, never has abused drugs, makes him a good candidate for the surgery. How else are you going to rid the glands that cause the pain? I don't have a clue. If there was another method besides surgery that actually worked everyone would be going with that method. But, surgery is the only successful option at ridding the glands. Asprin and common medicines may only help the pain for a short while they definetely won't rid it. Nothing targets that area for pain. If something did there would be a medicine for that. I really don't understand because our insurance companie right now has stated that same fact about the pain. What have you done to treat it? SURGERY FOR GLAND REMOVAL IS THE ONLY POSSIBLE TREATMENT METHOD. Like I said before if there was another 100% successful method everyone would be doing it. I don't know if I really can help you with your battle with BCBS but, basically  you have to tell them to give you proof of other successful methods. And one thing is you have to understand and trust me that there are no other successful methods and I am sure you and your husband already knew that. What insurance companies stoop to now days is rediculous. Insurance companies cover pain that inhibits daily activities. Or pain that affects your daily life. Your husband needed something to stop the pain from the glands and I can tell you the method you chose was the only and correct method. Just keep trying with BCBS and maybe you can get a doctors note and some surgeon notes backing up the statement that gland removal was the only possible treatment method. Because most of the time the gland is pretty dense or hard and can only be removed. No medicine breaks it up. Good luck and I hope I helped somewhat. Sorry to hear you have to go through this crap as well.

[olderguy]

There are a few physicians who call themselves "andrologists" and specialize primarily in infertility and sexual function.  It is not yet a recognized speciality.  Urology is the closest thing there is to a recognized specialty in men's health.  It is therefore not surprising that BCBS asked a urologist to review the claim.  An endocrinologist would also have been a good, perhaps better choice.  It is surprising if the urologist said that antiobiotics should have been tried before surgery.  Unless he is incompetent, he should have said "anti-estrogens."  As Nothingworse already said in his post, antiestrogens such as tomoxifen are the only medical (non-surgical) treatments for gynecomastia.  Apparently, tomixifen did not work for Nothingworse.  There have, however, been recent studies in Britain showing that treatment with a three-month course of tamoxifen is successful in more than 70% of cases of recent-onset painful gynecomastia, with no adverse side-effects.

I am 64 years old and developed tenderness in both breasts about six months ago.  My family doctor did hormone tests and found that testosterone was in the low-normal range, LH (luteinizing hormone) slightly elevated, and thyroid normal.  He ordered an MRI to rule out a pituitary tumor.  He sent my to a general surgeon to examine the small lumps, especially in my right breast, to rule out cancer.  The surgeon said that cancer was unlikely, but he wanted to remove the lumps anyway.  My family doctor preferred to wait a few months before anything as drastic as surgery.  I am asked him about tamoxifen and he said he would rather not take the risk of messing with natural hormone levels and would recommend surgery rather than hormones, but only if the pain became really bad.

As of now, either my nipples are less sore than they were six months ago, or I have become used to it.

I am covered by Blue Cross of California.  After the surgeon recommended removal of the lumps, I called Blur Cross to be sure that the procedure would be covered if I elected to have it.  The agent said that removal of painful lumps should be covered and not considered "cosmetic," but she also said that she could not guarantee coverage.  As far as I could determine, there was no way to get preapproval.  They would evaluate the claim only after it had been submitted.  I thought that not very helpful.

You should ask your family doctor and the surgeon to document the case-history and pursue the appeal.  No one should suggest a conservative treatment with antibiotics.  Furthermore, one might well choose not to try a so-called conservative treatment with anti-estrogens, because there have been few studies and there are risks with taking hormones.  However, if your doctor did not at least do blood-tests to check testosterone and other hormones and did not do a pituitary study if the hormone levels were abnormal, then I would have to agree that the surgery was premature.

I am assume that the hormone tests were in fact done and found to be normal, so that there would appear to be no need either for an MRI or to try a course of anti-estrogens.  If your doctors can document those facts, and if the pain was as severe as you say, then Blue Cross really should cover the surgery.