Insurance Coverage and Specific Gyno Exclusion

[bmwcro]

I have a CIGNA policy that specifically excludes gynecomastia and macromastia.  I submitted a pre authorization for gyno surgery and it was declined (*initial customer service policy determination was medical neccessity).

Thereafter, I sent a clarifying request for: surgery code OP 19101; OP 88307 which is incision into breast; remove mass of tissue for biopsy, biopsy itself.  The tissue is painful and may be cancer--- not being done for cosmetics. *I have a family history of cancer.

Do the codes 19101 and 88307 fall under the exclusion?

I specifically asked for a pre-authorization for this surgery and CIGBA said pre authorization is not required however the surgery is subject to policy and its exclusions.
 
The language on the cigna website is vague.  I may have to get the surgery complete and file suit.


Thoughts

[Paa_Paw]

Be careful of what you are getting into.

Your surgeon would likely be an oncologist or general surgeon. We have seen scars from such procedures that are really nasty.  Leaving the Gynecomastia alone would actually look better. The alternative would be a needle biopsy which would eliminate the cancer possibility but not serve to reduce the breast size.

There are very good reasons why cosmetic surgery is a recognized specialty. If you get a botched job there is no recourse and you'll get to repent of your hasty decision for a very long time.

[Dr. Elliot Jacobs]

Most companies have a set of criteria for coverage of gynecomastia surgery -- unfortunately they are very strict.

In general, the companies may cover for gynecomastia due to Klinefelter's Syndrome, a genetic disorder.  They may also cover if it has been present for over two years, provides emotional distress (this has to be documented by a separate mental health professional), etc.  They will not cover for obesity or if the patient is under 18.  As you have seen, many companies keep their criteria intentionally vague so they can interpret it to their benefit (not to yours) in any one particular case.

If you are absolutely counting on your insurance to be helpful, then I would suggest you try to iron out everything prior to any surgery. 
Trying to appeal or file suit after surgery will be time consuming and probably very expensive.  You might win in the long run -- but it will have cost you a fair amount of money.

Dr Jacobs