insurance wont cover surgery

[apopolow]

My 16 yr. old just confided in us that he has this. We went to the DR. and he submitted the insurance forms and they denied it, saying it was plastic surgery for cosmetic purposes.  I need materials showing the long term affects of this disorder so i can fight the insurance company.Can anyone help?   thanks     apopolow

[303MattS4]

Try doing a google search for 'gynecomastia + insurance company' and you can usually find their surgical treatment coverage policy; however, most of the time is seems pointless as they mostly consider this surgery cosmetic. For instance, Cigna states that will cover the surgery as medically necessary for either of the following conditions:

•   Klinefelter's syndrome
•   Either pubertal (adolescent) onset gynecomastia that has persisted for at least two years OR post
        pubertal-onset gynecomastia that has persisted for one year, when ALL of the following criteria are met:

        ␣ Glandular breast tissue confirming true gynecomastia is documented on physical exam and/or mammography.
        ␣ The gynecomastia is classified as Grade II, III or IV per the American Society of Plastic Surgeons classification.
        ␣ The condition is associated with persistent breast pain, despite the use of analgesics.
        ␣ The use of potential gynecomastia-inducing drugs and substances has been identified and
           discontinued for at least one year, when medically appropriate.
        ␣ The gynecomastia persists, despite correction of any underlying causes.
        ␣ Hormonal causes, including hyperthyroidism, estrogen excess, prolactinomas and hypogonadism
           have been excluded by appropriate laboratory testing (e.g., with levels of thyroid stimulating hormone [TSH],     estradiol, prolactin, testosterone and/or luteinizing hormone [LH]) and, if present, have been treated for at least 12 months    before surgery has been considered.

They also go on to say that they won't cover liposuction as the sole method of treatment, nor will they cover the surgery if it is performed solely to improve appearance or to improve psychological or psychosocial complaints.

That being said, it's an uphill battle but I've seen a few members on here that have had at least part of their surgery costs reimbursed by their insurance company.

When Dr. Jacobs asked that I post about the experience I had with him, I heartily agreed.  I'm in my early 20s, and I had suffered from gynecomastia for nearly 10 years.  I had thought about surgery in the past, but I had never seriously pursued the idea until I came across a profile of Dr. Jacobs in the New York Times.  I didn't realize that doctors actually specialized in this surgery.  I immediately made an appointment for a consult with Dr. Jacobs.

That consult was in January of 2009, when I was visiting New York.  I waited for quite a while before I jumped into the surgery.  I looked into a few doctors in Chicago, closer to where I lived, but no one did the volume of surgeries that Dr. Jacobs did.  I also felt more comfortable with Dr. Jacobs because I could see the results of many patients on his website, while other doctors only posted 2 or 3 sets of pictures.  Dr. Jacobs was a bit more expensive than the other doctors, but I felt that his experience justified the costs.  I finally made an appointment for surgery with Dr. Jacobs in September of 2009.

My surgery experience with Dr. Jacobs was excellent.  The surgery went well with no complications.  In addition to liposuction, Dr. Jacobs made small cuts and excised glandular tissue from under the nipples.  The scars healed quickly and are nearly invisible today, which is great because I usually scar very easily.  I have gained a little weight since the surgery, but my chest remains flat.  I am extremely pleased with my experience and results.

The total cost for the surgery and anesthesia, pre-insurance, was $6950.  Dr. Jacobs's staff subsequently filed all the insurance paperwork, and my insurance reimbursed about $2000.  The surgery was on Tuesday, I was walking around on Wednesday, and by Saturday I was well enough to move boxes and furniture for a relative.  By far the most uncomfortable part of the whole process was wearing the compression garment.

I posted a few pictures online so that you can see the results.  I'd be happy to answer any questions you have.

Before
After

I think your best chances of success will be to document the physical pain of his gyno and possibly make an appt with an endocrinologist to check his hormone levels and include that documentation in your appeal as well. I don't want to make this sound like a sure-fire way to get coverage (as most people elect to not even bother with insurance), but it might give you some ideas to beat your insurance company.

Good luck!

[dbugmom]

I just went through this same scenario with my 15 year old.  At first we were denied, but I filed an appeal and won (12-30-09).  My son had his surgery on 12-22.  We went into the surgery knowing there was a slight possibility that we could end up paying for it ourselves.  I filed the appeal 4 days before surgery.  My insurance company told me that if we won the appeal, we would be re-imbursed.

Because this condition usually resolves itself by the time a teen is done going through puberty, that is why most insurance companies won't cover it.  However as with my son's case, we had the problem documented.  We saw the pediatrician 2 years ago when we first noticed the issue.  The guidelines for my insurance company was that the problem has must persist for at least 2 years, and it must be a certain degree (the mose severe - my son's was a 3 / 4 on their scale, with 4 being the worst).  Also, they wanted to make sure there were no pathological causes for the gynecomastia (hormone issues).  We saw an endocronologist and had those issues ruled out.

I truly feel for your son, but from my experience, if he is just telling you about this now (which is good that he is telling you at all), you will have to give it time to see if it resolves itself before your insurance company will consider paying. 

Please feel free to ask me any questions you may have.  My son is just about 3 weeks out from surgery and we couldn't be more pleased.