Insurance appeal declined

[Denman]

I am a 52 yo male with mild gyne. A cosmetic surgeon that I went to submitted a pre-authorization request for surgery, and it was declined. Then I appealed that directly to the insurance company, and it was declined again. Then I appealed that to a state insurance commission and after sending lots of documentation to support medical necessity, it was firmly declined for the last time. According to the insurance company, gyne surgery is specifically excluded by the "certificate of coverage" of my [former] employer, through whom I have cobra coverage. In other words, it appears that the employer has some influence in what is covered and not covered when they contract with the insurance companies to provide coverage for employees. I don't like the idea of the insurance company counteracting medical necessity in this way, but I accept the final decision and will move on.

[Paa_Paw]

Medical insurance is often purchased on the basis of cost.

In order to reduce the cost of a plan, the insurance company will write a number of exclusions into the plan. Since Gynecomastia seldom has any associated pathology they can cover the cases where pathology is present but exclude coverage for any other reason thereby holding their liability to a minimum and keeping the overall cost of the policy low.

Surgery for Gynecomastia is covered by only a few policies and they are the most expensive and comprehensive policies you can buy.

One way or another, you wind up paying for the surgery  yourself. Either as a separate item or as an inclusion in a policy at an inflated price.

Several years ago a young man was elated to report that he was having surgery and his insurance was covering the cost because he had a malignant growth. A general surgeon did a lumpectomy on one side only without much regard for the direction of the incision and the result was hideous.  Be careful what you wish for.