Are exclusions absolute?

[anon553]

I'm looking into two insurance plans.  Plan A (PPO) allows surgery for gynecomastia if medically necessary.  Plan B (HMO) simply lists it under EXCLUSIONS...does that mean the procedure is excluded for all patients, even when deemed necessary?

[Litlriki]

I would not purchase your insurance based on whether or not you think your gynecomastia surgery will be covered.  Mainly because it probably won't be covered.  Recently, some strange things have been happening in our insurance markets, and I can't help but think that it's a response to the legislation surrounding the new health care bill.  I'm a little confused, since in Massachusetts, we already had "universal coverage."  Based on my conversation yesterday with someone in the contract department at Blue Cross, surgery for gynecomastia with the CPT code of 19300 is not covered.  Ever.  I am exploring if there is some other code that would be applicable for some patients, but this is the code that I use currently, and Blue Cross, as the biggest insurer in the state, doesn't pay for it.  I don't mind that it's not covered, but I have to know how to advise my patients.

Rick Silverman

[anon553]

Thanks Dr. Silverman.  It's unfortunate that this double standard exists with regard to chest reconstruction.  Women are routinely approved for breast reconstruction post-mastectomy, but men like me who've lost weight have no recourse when it comes to gynecomastia.  While cancer does present a more imminent danger, obesity is also lethal, albeit insidiously.  One day, I hope people who overcome a disfiguring disease can find an affordable remedy regardless of sex.

Until then, I'll have to keep saving up.  Thanks again for the advice.

[Dr. Cruise]

It is highly unlikely an HMO will cover gynecomastia.  An exclusion typically implies the procedure is not covered, even if you think its medically necessary.