To put it short - I am pretty poor right now and am looking for insurance to cover my gyno. Anyway, I asked them about it and this is the info they sent me. Hopefully this helps some people who are looking for help from an insurance company.
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WellPoint Health Networks
Clinical Guidelines
SURGICAL TREATMENT OF GYNECOMASTIA
Specialty: General Surgery
Category: Outpatient Surgical
DEFINITION:
Gynecomastia is an increase of breast tissue in males. True gynecomastia consists of proliferation of both ductal and stromal tissue and results from conditions that cause an imbalance in the levels of serum androgens and estorgen, (i.e., either estrogen excess or testosterone deficiency). Estrogen excess occurs infrequently, as a result of estrogen-secreting tumors. More commonly, a relative excess of estrogens is present when serum testosterone concentration is reduced. The testes are the source of virtually all testosterone in plasma. Thus, disorders that reduce testicular hormone secretion remove the major source of plasma testosterone but have much less effect on circulating estrodial, producing a situation of relative estrogen excess. (1)
During three phases of male life, breast enlargement can be regarded as physiological rather than a pathological event, as follows:
- neonatal gynecomastia (possibly related to the action of maternal and/or placental estrogens);
-adolescent gynecomastia (transient enlargement of the breast is a normal occurrence in male adolescence, usually lasting from 6-18 months);
- gynecomastia of aging (common benign occurence related to decreased levels of plasma testosterone and relative estrogen excess).
Notably, this condition in the older male (age of 60 and beyond) can also be an indication of underlying pathology, (i.e. related to chronic/genetic disorders, medications, etc.). For this reason, caseful clinical evaluation is warranted to rule out disorders of the cardiovascular system, liver, or other etiologies. (2)
MEDICAL NECESSITY:
HPI/PMH:
Patient is a male without evidence/suspicion of an underlying causative and correctable condition, (e.g., liver disease, testicular malignancy, endocrine disorder, drug induced condition) with pain syndrome that:
- has a clinically significant impact upon activities of daily living; AND
- has been refractory to a trial of analgesics or anti-inflammatory agents (for a reasonable time period adequate to assess therapeutic effect); WHEN
- confirmatory photographs are provided.
MEDICAL ISSUES
Pain complex necessitate the use of analgesics or anti-inflammatory agents.
DIAGNOSTIC TESTING:
Appropriate diagnostic evaluation has been done for a possible underlying etiology.
SETTING:
Outpatient
TREATMENT ALTERNATIVES
Continued conservative treatment (weightloss may be indicated).
ADDITIONAL INFORMATION:
Physiological gynecomastia usually occurring during adolescence (from approximately ages 10-16) is usually transitory and should be observed for 12-24 months before surgical options are considered.
Unilateral gynecomastia in post-adolescent age groups may have serious pathological importance. An evaluation and subsequent excision, when warranted, should be authorized without an observation period.
The presence of gynecomastia outside the age groups considered possibly physiological, (i.e., neonates, adolescence, old age) warrants clinical evaluation for possible pathological etiology, prior to any surgical interventions.
NOTE:
Some benefit plans may specifically exclude this service
Please refer to the member's certificate of coverage for available benefits.
Some benefit contracts may include a reconstructive benefit which may be applicable.
Group specific policy and/or state mandate may supersede this guideline, when applicable.
Topic: My insurance company's guidelines on gyno (Read 2920 times)
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