Coverage..costs???

[deadpirate]

I am curious. I have seen some people talk of insurance covering a portion of the surgery. Does anyone know under what circumstances insurance companies will do this?? I have no problem forking out the money to get this done, have been saving for 2 years but if i can get some of it paid for, all the better.

[Paa_Paw]

Generally speaking, you will need to prove that there is a medical problem or a medical need.

Since the worst effects of gynecomastia ar psychological, The best source for help would be a Psychologist.  Unless you are one of those rare people who developed Gynecomastia as a result of a pituitary tumor etc.

The Psychologist's report would need to indicate severe emotional stress, problems socializing etc. and indicate that these were caused by the Gynecomastia.

If your Gynecomastia was caused by unprescribed steroids etc. or drugs like Finasteride, (Propecia) You will face the probable opinion that you caused it yourself and have little to no chance of insurance coverage.

[Fajha]

My surgery was fully covered by my medical insurance.  I am in California and my carrier was Blue Cross.

I spent time with an Endocronologist first who ran a battery of tests first.  Once proven that this was not caused my me, she suggested surgery.

Paa Paw said, it was covered primarily due to psychological issues that the condition causes.  More and more carriers are covering it these days.

Good Luck.

[Fajha]

Fajha -

I am a BCBS PPO member and would love to find out more about your process and criteria for coverage.

Which state are you in? Did you have to file any appeals? What did you have to prove?

I plan to go to an endocrinologist, and I've had the official diagnosis since 2002. What else will I have to prove?

Even partial coverage would be incredibly helpful.

Hi Brooklyn,

I am in California.  I had been going to the Endo for about a year.  She initially thought it would not be covered till she was having lunch with the Medical Director of Lakeside Medical Group.  He informed her that most insurance carriers cover this procedure these days.

For some reason, it was viewed similarly as a woman needing a Breast reduction for medical and mental health reasons, or a cancer patient needing re-constructive surgery for the trauma such things can cause.

I did not have to appeal, it was all pretty straight forward actually - which I am grateful for.

I would suggest have your Endocronolist sending in a request for the procedure.

Fajha.

[infinity123]

To my complete amazement, my insurance company (health partners) covered the whole cost of surgery, without the need for appeal. Their criteria for coverage was pretty much the following: gynecomastia has been present for a significant amount of time (meaning it most likely won't go away on it's own, as it sometimes does in adolescence--I am in my 30's, by the way), it can't be resolved by treatment (such as hormonal treatments), it's not due to obesity, and it meets a fairly subjective measure of "severity" (they cite a scale, which I think refers to the "Simon scale", named after a published paper by Simon). In my case, I had a consultation with a plastic surgeon first, and then the PS submitted this information in a letter to the insurance company in order to request authorization.

Good luck to you! And thanks to those gyne patients and medical activists who seem to have made it easier to get this procedure covered by insurance.

[tomorrow]

I too am having the proceedure covered by insurance. I had to file an appeal but its all straight now. Just make sure you've seen a Doc and an Endo, site emotional and/or physical discomfort, and include photos. Do your best to make the problem look as bad or worse than it is (i.e. hunch over). Being overweight won't help your cause so make sure its a real issue and not just obesity.