Conditional approval from Insurance!

[wvalum07]

I received some great news yesterday! I've suffered from gynecomastia for 20 years now. Began developing when I was 10. I spoke with my insurance company yesterday to see if they covered corrective surgery. They indicated they do in fact cover it if you meet the criteria posted at the end of post.

***Now I currently weigh 197lbs, but only 15% body fat. In order to meet the 25 BMI, I need to get down to 185lbs, which I will work my ass off to get to.

However, I wanted to see if anyone has had experience with having insurance paying. It says that if the criteria isn't met, they will still cover the surgery IF it documented in a pathology report that it is breast tissue and not fatty tissue. Is that something they would do a biopsy during a workup, or once they take the gland out in surgery?

Sorry for the long post!!

Mastectomy for gynecomastia (19300):

The American Society of Plastic Surgeons" classification system of gynecomastia is as follows:

Grade I: Small breast enlargement with localized button of tissue around the areola

Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest

Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy

Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast

Mastectomy for gynecomastia is considered reconstructive when the patient meets the criteria for Grade II, III, or IV; AND,

For boys 16, 17, and 18, whose body mass index (BMI) is less than the 75th percentile for age; i.e., a BMI of 22.7 for age 16, a BMI of 23.4 for age 17, and a BMI of 24.1 for age 18

For men over age 18, a BMI of 25; AND,

When pathologic gynecomastia (e.g., hypogonadism, endocrine disorders, metabolic disorders, neoplasms, and male breast cancer) and pharmacologic gynecomastia (i.e., gynecomastia induced by pharmacological agents, including but not limited to, cimetidine, digitalis, methadone, marijuana, clomiphene, chemotherapeutic agents, anti-retroviral agents, herbal remedies, chlorpromazine, and anabolic steroids) have been excluded.

If the above criteria are not met, it must be documented that the tissue is primarily breast tissue, by pathology report, and not just adipose (fatty) tissue.

[hammer]

Actually, that was very good information, thank you!