My insurance experience

[Denman]

After visiting a surgeon who does gyne surgery and is connected to my health plan, my pre-approval was denied. I then appealed it to the insurance company, stating that the surgery is for pain, not just appearance. The appeal was denied, and this is the exact wording, bracketed within solid line for clarity:
___________________________________________
According to your Benefit Plan:

The following services are excluded from coverage from both network and non-network:

Cosmetic Procedures-procedures or services that change or improve appearance without significantly improving physiological [well being]

Examples include:

-Liposuction or removal of fat deposits considered undesirable, including fat accumulation under the male breast and nipple.

-Treatment of benign gynechomastia (abnormal breast enlargement in males).
______________________________________

Yes, this is a cosmetic surgery, but no, it is not just to improve appearance, it is to reduce physical pain. So it is not just cosmetic, but it is performed by a cosmetic surgeon. 

I could appeal this to a higher insurance commission, but not sure if I will get any farther.

[hammer]

It is a bunch of BS, but that is the way most insurance co are! Last year dr. Jacobs and I tried to get a letter campaign going to dr. Oz to do a show on gynecomastia, and it went no where! I have no idea how many letters were written, but I never received in invite to be on the show nor did dr. Jacobs, and the only thing that I ever heard said about gyne on the show was it was a side affect to a treatment. We had hoped this would open the eyes of people and insurance co to the wide spread problem men are facing with gynecomastia.

You can appeal, but you could end up with a undesirable physiological label in your record.


Good luck!
Bob

[xelnaga13]

I got mine covered. The trick is to call your insurance company and find out what kind of medical proof they need to cover the surgery. Unfortunately once your denied it becomes and uphill battle.

[Denman]

On the back of the denial from the insurance company, they gave a way to appeal further, it would be to the Illinois Dept of Insurance. Not sure if it is worth the effort. It seems a little unfair that surgery is the only option to fix the problem, but the insurance company specifically lists it as a non-covered service. What do they expect to happen? It doesn't go away. There are not other fixes.

[mikesmom]

I can totally relate to your disappointment as my sons surgery for severe gyne was also just denied last week. The surgeon said that with our insurance coverage it shouldn't be a problem to have it covered as I work for a state law enforcement agency and we supposedly have great insurance coverage!
This I guess is debatable.

As a single mother of two young men, I cannot afford the surgery out of pocket but am seriously thinking of quitting my job to pull my retirement for my sons.
But that means I would have to choose between college money for them or the surgery. I may have to have both of my sons gyne surgically removed. They are 17 & 18 yrs old but the 18yr old has the most issues. He has been bullied since 7th grade for something that he has no control over and was told by our GP that he would grow out of it. Well, he's 6'2 at 215lbs and almost c-cup gyne.

Both are seniors in high school, they both exceed in all their studies and will graduate 2014 . But my son has not been able to live life as a happy young man. Even in 118 degree weather he wears thick sweaters to cover his chest. His back always hurts him and he rarely goes anywhere. How does a company that I pay every 2 weeks no less than 300 dollars determine that he has no "functional deficit'?

I have no idea how to handle this or an appeal to United Healthcare of Arizona. If anyone has any advice: I am all ears!
Any advice is welcome.

[sullyman]

On the back of the denial from the insurance company, they gave a way to appeal further, it would be to the Illinois Dept of Insurance.

I am about to go to this step, for a claim with BlueCross BlueShield of Illinois.  Unfortunately (in hindsight), I trusted my surgeon's office when they told me (because BCBS told them) that the procedure last June was covered because it was outpatient.  After the fact, coverage was denied and I've been in a constant state of appeals and negotiations (with the hospital who wants their money) since July.  The Department of Insurance external review is my next step, followed by a possible civil lawsuit.

My procedure was only on 1 side and had very little to do with appearance, and everything to do with pain and swelling... hopefully that will be considered in these appeals.  I really do NOT want to sue the surgeon's office, but that seems to be the direction it would go since they assured me before the surgery that it was covered (and I believe they neglected to properly review the medical guidelines beforehand).  We shall see.

[Paa_Paw]

It has been several years, but I recall a case where a young man went to a Psychologist that his insurance did pay for and the Psychologist wrote a letter to the effect that the young mans' Psychological issues would require continuing treatment for years with little prospect of relief whereas the Surgery should be able to relieve the problems literally overnight. The Insurance Company reconsidered and finally did cover the cost of surgery.

In that case the young man was severely depressed and socially withdrawn. He had very low self esteem. The Psychologist expressed the opinion that the ultimate cause of all the psychological issues was Gynecomastia.

I do not know if that case was a fluke or if any sort of precedent was set. But, What have you to lose for trying?