Blue Shield PAID FOR my Teenager's Gynecomastia SURGERY and YOU CAN TOO!!

[chringram]

If you found this then maybe it will help you?!
(I had found this SITE while working on my son's procedure and it was helpful so I bookmarked it and now that we DID GET INSURANCE TO PAY FOR IT, I can fulfill my vow to return and post the solution.) 


Since my son was a teenager with diagnosed Gynecomastia it was troublesome to locate a surgeon who would help. In fact there was one in Beverly Hills who believed my son should lose significant weight and he would not touch this case. Prick!
None-the-less, and in the words of a great singer, "we never weary!"
We found a FANTASTIC SURGEON who was AWESOME at the "Surgery Center Of South Bay," then scheduled the surgery, took out a credit card to pay for it, had the procedure done, then filed for reimbursement from the Blue Shield PPO. 
Although the claim was denied, what follows is my APPEAL letter. This approach worked!! My letter coupled with the fact that Blue Shield messed up the claim and sat on the response too long rendering them no other choice but to reimburse me helped seal the deal. There are links provided as well in case you need to reference things.
TIPS TO KEEP IN MIND

1. Call insurance company's customer support frequently and document all calls and communication. This includes: who you speak with, who their manager is, what was discussed, ask for a reference ID # for the conversation. Keeping a running log of all communication (phone, mail, fax, etc) limits their options for further denial
2. The practice of removing large amounts of tissue is working to eliminate the opportunity for CANCER. Drop that in your responses when you can.
3. Demand (in writing) the insurance company put things in easy-to-understand language with detailed explanations on any decision they make. Their 'auto-generated' forms that insurance companies mail you NEVER have this information, but by law they have to provide. Example is: I HAD RECEIVED INFORMATION THIS CLAIM REFERENCED ABOVE WAS NOT SUBJECT TO DEDUCTIBLE AND REQUESTED A COPY OF THE JUDGMENT AND RELATED FINDINGS. I HAVE NOT RECEIVED THIS INFORMATION. UPON RECEIPT OF THIS FAX, PLEASE SEND ME A COPY OF THE SCIENTIFIC OR CLINICAL JUDGMENT USED FOR THE DETERMINATION OF THIS CLAIM. .... When they don't respond to this request and 30 days go by, they did not follow the letter of the law and are no longer in compliance.
5. Since we had Blue Shield, this link below was a great resource that defined their ACCEPTANCE criteria for covering the procedure: www.empireblue.com/medicalpolicies/policies/mp_pw_a053474.htm
6. There are more links below, here are some not included in the APPEAL letter that helped me!
http://www.npr.org/sections/health-shots/2014/04/14/302547851/patients-often-win-if-they-appeal-a-denied-health-claim
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APPEAL RESPONSE. (So now to the meat of it all! My son's surgery was denied on the basis of 4 different areas. My appeal dealt with each of them. Enjoy and .... God willing... I hope it helps you all!!)
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DATE: xx/xx/xxxx
Patient Name: NAME <DATE OF BIRTH>
Relation to Subscriber: <DEFINE RELATIONSHIP>
Diagnosis: 757.6 Specified congenital anomalies of breast
Provider Name and Address: < ADDRESS, TELEPHONE, FAX >
Insured: <YOUR NAME>
Subscriber Number: <YOUR NUMBER>
Group Number: <YOUR GROUP>
Dates of Service: <DATE>
Procedure Codes: CPT Code 19300 Mastectomy for gynecomastia
Claim number: <CLAIM>
Dear Claims Review Department,
I have decided to appeal your decision to deny coverage of my son’s recommended treatment plan of mastectomy for gynecomastia. Since my son’s diagnosis, the serious medical condition has adversely impacted his life and daily activities. He had already tried various other treatments for the condition which are outlined below. These are the basis for the rationale used to determine that <PATIENT NAME> have the mastectomy. There was significant relief which followed the surgery. Mastectomy to treat gynecomastia has been proven to have an extremely low complication or re-admission rate and regularly covered by private payers such as Bupa and Aetna. For your information, I have attached related lab and test results and have referenced medical studies, and articles from scientific journals regarding this procedure. Please take the following into consideration while reviewing this appeal.
Thanks,
YOUR NAME
YOUR CONTACT INFO

BACKGROUND: The patient had undergone careful physical evaluations and testing to identify possible etiologies. Longstanding gynecomastia was diagnosed and coupled with the resulting traumatic interference of the patient's activities of daily living, further suspicion of malignancy of breast warranted surgical treatment. Given the severity of gynecomastia could not be remedied through other medical therapies this rendered the only effective solution as surgical removal of tissue.
SUMMARY: Per Blue Cross Blue Shield (BCBG) medical plan language Mastectomy for Gynecomastia is covered when deemed medically necessary. The claim was denied based on the basis of four (4) points. The following responses provide clear insight into the patient’s medical condition, each of which justify the medical necessity of the surgical procedure.
CAUSE OF DENIAL: Patient is greater than 18 years of age or 18 months past puberty
APPEAL RESPONSE: Patient lab results indicate a lack of a growth hormone, an underlying cause of gynecomastia which contributes to delayed puberty. In such cases, mastectomy is indicated regardless of age to properly address concerns. Denying a claim due to an age dependency in a patient who has a documented lack of growth hormone would highlight that the denial was based on a previous medical condition and against federal law. Further, the mastectomy procedure for gynecomastia is considered medically necessary, regardless of age, when there is legitimate concern that a breast mass may represent breast carcinoma.
CAUSE OF DENIAL: Documentation does not indicate that gynecomastia is associated to any condition other than patient’s weight
APPEAL RESPONSE: This is a poorly defined association which confuses the medical diagnosis of gynecomastia with pseudo-gynecomastia. Patient’s records clearly show lack of excess fat deposition in material biopsied as a result of the surgical procedure. In the patient’s case, longstanding gynecomastia and the suspicion of malignancy of breast further warranted the surgical therapy. Additionally, the following was confirmed by the examining physicians and provided with the claim’s original documentation:

• Patient has pain or tenderness directly related to the breast tissue (documented in the medical record) which has a clinically significant impact upon activities of daily living and has been refractory to a trial of analgesics or anti-inflammatory agents
• Pre-operative photographs were provided displaying the severity of gynecomastia

CAUSE OF DENIAL: Documentation does not indicate glandular breast tissue has been confirmed on physical exam and/or mammography or tissue biopsy
APPEAL RESPONSE: Patient’s severity of increased and hardened breast tissue was confirmed by examination and presented in the claim paperwork. Gynecomastia, being a proliferative condition of the male breast, can occasionally lead to concern about the development of carcinomatous changes in the breast. In some cases, biopsy results do not lead to a clear distinction between non-cancerous and cancerous breast tissue. Thus the tissue was removed surgically to eliminate any further risk of carcinomas.
CAUSE OF DENIAL: Documentation does not indicate underlying etiologies or contributory conditions have not been considered or excluded and/or treated
APPEAL RESPONSE: Treatment of the identified underlying conditions was attempted prior to the discussion of surgery. Appropriate diagnostic evaluation had been done for possible underlying etiologies including ultrasound of the thyroid, abdomen, & gall bladder; bone age study; bioimpedence analysis; and blood work. These tests identified an imbalance in IGF-1 and ACTH levels. Medical findings indicate the GH/IGF-I axis is involved in the pathogenesis of gynecomastia. These values recognized in the patient blood work highlight deficiencies that isolate the associated etiology of the diagnosed gynecomastia as well as document the patient’s risk of cancer if left untreated. Attempts to treat failed leaving the surgical procedure as the only option to lessen future risk to the disease state of the patient.
PROCESSING DELAYS: Our initial claim for this procedure was mailed on <INSERT DATE OF ORIGINAL CLAIM>. I did not receive an update of the denial until several months and numerous support line phone calls later. Additionally, I still have not received a response to my request for the scientific judgment and related findings used to determine the denial. These experiences are outside of the boundaries allotted by the ERISA act of 1974. You must respond within a timelier manner as my medical policy dictates. Any further delays to this appeal process will force me to file a federal grievance complaint.
REFERENCES:
Gynecomastia associated with isolated ACTH deficiency.; J Endocrinol Invest. 1987 Apr;10(2):127-9. Shimatsu A, Suzuki Y, Tanaka S.  http://www.ncbi.nlm.nih.gov/pubmed/3035001
Elevated serum IGF-I, but unaltered sex steroid levels, in healthy boys with pubertal gynaecomastia; Mieritz MG, Sorensen K, Aksglaede L et al. Clin Endocrinol (Oxf). 2014 May;80(5):691-8; http://www.ncbi.nlm.nih.gov/pubmed/24033660
Gynecomastia: Etiology, Diagnosis, and Treatment; Ronald S. Swerdloff, M.D. Professor of Medicine, Chief, Division of Endocrinology, Assoc. Chair, Dept of Medicine,Harbor-UCLA Medical Center,1000 West Carson St, Box 446, Torrance, CA 90509-2910; http://www.ncbi.nlm.nih.gov/books/NBK279105/
Breast malignant, males, children Male tumors Gynecomastia in males; Reviewer: Monika Roychowdhury, M.D.; http://www.pathologyoutlines.com/topic/breastmalignantgynecomastia.html
ASPS Recommended Insurance Coverage Criteria for Third-Party Payers; American Society of Plastic Surgeons; http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/insurance/Gynecomastia-Insurance-Coverage.pdf
Gynecomastia: Etiology, Diagnosis, and Treatment. Authors Swerdloff RS, NG J. Editors In: De Groot LJ, Beck-Peccoz P, Chrousos G, Dungan K, Grossman A, Hershman JM, Koch C, McLachlan R, New M, Rebar R, Singer F, Vinik A, Weickert MO, editors.  Source Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-.2015 Aug 3. http://www.ncbi.nlm.nih.gov/pubmed/25905330