Need advice

[gray]

I have found two doctors in my area with gynecomastia experience and have corresponded with both via email. Now the confusing part, both participate with my insurance bc/bs. One says the procedure is sometimes covered, the other says it is almost always covered. Would this difference of opinion be caused by one having more experience dealing with insurance? I am kinda leaning towards the 1st, but with the other having more insurance success, it's hard to not go to him . There is also one report on this forum of someone having great results with him, and it was covered by insurance. Needless to say, I need to make an appointment where I can see photos of actual results. Just don't want to risk having insurance turn me down . How do I decide?

[DrPensler]

I suspect they do not treat much gynecomastia. In my experience it was typically covered until approximately 10 years ago.It is not covered today . I have spoken to multiple insurance companies about this.I spoke several years ago to the medical director for Blue Cross. The medical director told me that as a former pediatric surgeon, he personally thought gynecomastia should be covered however it was the policy of Blue Cross that it was not covered under any circumstance with one exception. The one exception was biopsy proven cancer.

[Litlriki]

Insurance policies vary from state to state and individual insurance companies vary in their coverage policies.  Blue Cross/Blue Shield of Massachusetts has set criteria, which they consider for male breast reduction, and those criteria are fairly effective at guaranteeing that they almost never cover this procedure. Other insurers are more vague but also rarely cover the procedure here.  It may be that the surgeons you've spoken with code the procedure as a breast biopsy, rather than treatment of gynecomastia, but this isn't really allowed, and most gynecomastia surgeons don't do it.  If you're confident in the surgeon and you can get the procedure done through your insurance, go for it.  But you should also be sure to understand what implications there are if payment is denied--what are you responsible for?  I say this, because even when insurance companies grant "prior authorization," at the end of the authorization letter, it states that "Prior authorization does not guarantee payment."  It would be awful to get a surprise bill after your surgery.

Rick Silverman

[Dr. Elliot Jacobs]

Totally agree with Drs Pensler and Silverman.  It has been my experience that gynecomastia surgery is very rarely covered by any insurance.  The companies have their own very strict criteria which just about make it impossible for anyone to be covered.  They simply call it "cosmetic" and refuse to cover it.

One of the problems is that liposuction, which has been around for over 30 years, is considered cosmetic no matter what the context.  To me, the use of liposuction is the same as using a scalpel or a scissor -- it is just a surgical instrument used to achieve a result.  Unfortunately, if the word "liposuction" is used in a gyne operative report, it is considered cosmetic and is immediate grounds for rejection.

Since the insurance companies are the only game in town, there is no higher authority where one could appeal.

Dr Jacobs

[gray]

I was able to pull the criteria my insurance company has listed. It says it will cover gland removal by scalpel, but not liposuction. Perhaps this is all that the two doctors I mentioned are submitting? I know the insurance also requires pre-certification. Something tells me I'm gonna get stuck with a bill.

[Dr. Elliot Jacobs]

Ahhh, here is the rub.  Most gyne operations require both scalpel excision as well as liposuction to get the best possible results and contours.  Scalpel excision of gland alone can sometimes lead to a crater deformity. The surgeon then evens everything out with liposuction of the surrounding tissues.

The surgeon is thus placed in an ethical quandary.  Should he only mention scalpel excision in his operative report (even though he may use lipo as well)?  In essence, this would mean he is submitting an operative report that is incomplete and therefore not totally honest.  On the other hand, if he mentions scalpel excision and then the use of lipo as an adjunct, then the claim could be rejected as cosmetic and this would be unfair to the patient, who is hoping for reimbursement.

The problem lies with the insurance company making their own rules about liposuction.  Lipo is used in many ways -- and not all of them is cosmetic in nature.  Yet the insurance companies equate lipo with cosmetic.  Unfortunately, there is no higher authority to oversee the insurance company's own definitions.

Dr Jacobs

[gray]

Interesting thing is someone posted on here about having surgery with one of the two doctors I am considering. He had both excision and liposuction, and bc/bs covered 100%.  That was around 5 years ago. Guess it will make for some interesting consultation conversations.

[Litlriki]

It's possible that the surgeon submitted a bill for breast biopsy, and that's all he charged for--and that's what the other poster had done. It may have included liposuction, about which he dictated or not--None of us know that. Plus, that was five years ago. I don't know what state you're in, but these things vary from state to state and coverage changes from year to year, cutting back on what's covered.  In Massachusetts, we're way ahead of the curve, and gynecomastia hasn't been covered here for many years except in very rare instances.

RS

[gray]

Ha! I'm in birmingham, alabama. Not sure we are on the cutting edge of anything
It has been frustrating trying to find, a gyno surgeon. I always figured with an outstanding med school like uab here, there would be plenty. Yet very few even list it among the procedures they perform. I found the two I am considering by chance. One, as I mentioned earlier, was named on this forum ( he also claims gyno is almost always covered by insurance, which makes me nervous). The other I found through a bodybuilding site. I figured with some of those guys experimenting with steroids they would be familiar with gyno, and sure enough found a name they highly recommend. If I can find a way to load it, I will paste my insurance company's protocol on here. Might also post the letter from one of the doctors who says it should be covered. I will not name him however.