Got referal from Doctor - Insurance?

[MacMan]

My primary doctor gave me a referral to a hospital that has plastic surgeons. My gyno is bad enough that he said it was worth seeing if insurance would cover plastic surgery.

Is there anything I can do to increase the chance of insurance coverage?

I've had this since I was 31 and it's ruined my life. It's caused so much mental and emotional pain. I haven't been able to et into a relationship, have sex, or take my shirt off. I've worn a compression best every day for 7 years. I'm an ethical and moral person but I've finally realized that the only way I'm going to get set free from this HUGE issue that has effected my life is by either lying or exaggerating pain.

From what I understand most insurance won't cover the procedure unless physical pain is involved. I'm an extremely honest person but am realizing my only option is to exaggerate pain.

Is anyone aware of anyone who got gyno surgery covers by their insurance?

This is a pretty unethical question to ask I think--but oh well I'm desperate--is there any specific pain or symptoms I should fake or exaggerate to seem more believable?

I'm an honest, moral, and ethical person. It's not in my nature to lie like this but psychologically I've put up with this for so long I've reached the point where I just don't care if I have to exaggerate or out right lie. Judge me if you want.

Does anyone have any advice or experiences with this?

[Dr. Elliot Jacobs]

Most insurance companies do not cover surgery for gynecomastia.  The use of liposuction, which is an integral part of the surgery, is deemed "investigational" despite the fact that it has been around for over 40 years and virtually every single article on gyne surgery mentions its use.  Unfortunately, the insurance companies make the rules.

If you would like to see if gyne surgery is covered by your insurance, you should look into your own individual policy.  Policies vary greatly -- even within the same company.  Once you have looked at the specific criteria for your policy, step back and see if you can qualify.  If you think you are close, then perhaps your surgeon (or his billing company) can send in a pre-determination letter, in which your particular qualifications for the surgery are spelled out.  And then wait for an answer -- and be prepared to be rejected.  And then you can appeal their decision.  And if, by any chance, they subsequently approve the procedure, they will never tell you what they will pay.  

Finally, you will have the procedure and the bill will be submitted to insurance.  The insurance company may then decide not to cover the surgery -- quite arbitrarily. Remember, they make the rules.  And if you want to appeal, then you are appealing to some "higher ups" in the same company.  Talk about conflict of interest!!

The above scenario is the minefield that physicians deal with every day.  That is why I, as well as many of my colleagues, insist on payment for our services in full in advance.  It is my office policy, for example, to cooperate with a patient in submitting an insurance claim after the surgery has been performed.  And once in a while we get lucky -- but only once in a blue moon.

Just a little insight for you.

Dr Jacobs

[Paa_Paw]

A small number of expensive policies do cover the condition.
Some policies specifically exclude it. others specifically escludde any treatment by o Cosmetic surgeon.
I have heard several years ago of a young man who got surgery as the supposed only remedy for the young man's psychological problems, which were many.   

[rrr]

31 is a strange age to get gynocomastia - do you know what caused it?
Most cases start in puberty or past 50.
B

[MacMan]

Thanks for both of your responses. It's disheartening to hear how insurance Works.
I just called and booked an appointment with a plastic surgeon. I got a referal and the insurance is supposed to cover my consultation.

I'm guess the doctor will just tell me what I need to get done and what he can do--and that insurance will halt coverage at this point?

Should I expect the dr to tell me they require payment upfront since insurance is unreliable?

On the plus side the appointment is a couple months away. I have time to lose some weight and perhaps start putting some money aside.

[MacMan]

I just saw ur response. I've had gyno since I was 12 or 13. It got really bad when I was 16 or 17. It's gotten worse with weight gain. In my early 20s it became extremely noticeable with a shirt on. I've only ever been 10 to 20 lbs overweight.

[MacMan]

One other question. My gyno has been painful at certain times in my life. Although it's not persistent. Like sometimes the pressure from my seatbelt hurts so I don't wear it.

If I mention physical pain to the dr when I see him for a consult. If I can demonstrate that it's impaired me physically with certain things. Is there more of a chance insurance will cover it?

[Dr. Elliot Jacobs]

You can try -- but there are no guarantees.

Dr Jacobs