How can I best argue my case for coverage for male breast reduction surgery to my insurance company?

Question

What tests should I have taken prior? How many doctors' opinions should I get to say that I do indeed have a legitimate problem? I also know that the American Society of Plastic Surgeons has published a position paper encouraging insurance companies to cover certain gynecomastia cases. Should I send this paper along with my claim, or would they already be aware of it?

Jed H. Horowitz, MD, FACS · Answer

Typically, gynecomastia surgery is not always covered by many insurance or healthcare programs. If it is, it can take some time to acquire approval as criteria can be restrictive. If approved, it's possible to be reimbursed by the insurance company after the surgery. Thus, it may be best to speak to your insurance carrier after you consult with a plastic surgeon. Nevertheless, most plastic surgery offices offer convenient finance plans that allow patients to pay a low monthly payment.

According to the American Society of Plastic Surgeons the average #cost of #gynecomastia surgery can vary widely. #Surgery quotes should include the procedure itself, operating room facilities, anesthesia fees, surgeon’s fees, medical tests, post-surgery garments, prescription medication and other related costs.  Costs will also vary with geographic location. Estimated costs can be found here on RealSelf.com, PlasticSurgery.org or Surgery.org.

It is imperative you select a plastic surgeon who is #board-certified and has a great deal of experience with male breast #reduction. Plastic surgeons who have specialized in breast surgery and cosmetic surgery are suitable to perform your procedure. Aside from checking board-certification, it is suggested that you look at before and after photos of the surgeons actual patients, and read patient reviews. Gathering all of this information will help you make a well-informed decision.

Larry S. Nichter, MD, MS, FACS · Answer

From your description it seems as if you are a good candidate for gynecomastia removal. Unfortunately, each insurance company has their own criteria. Large breasts (macromastia) or breast hypertrophy can occur in a variety of conditions (family trait, post pregnancy, excessive adolescent growth). In general when the excessive breast size causes functional problems, insurance will generally pay for the operation if more than 400 – 500 grams are removed from each breast dependent on your individual insurance company requirements. These problems may include neck pain, back or shoulder pain, hygiene difficulty, and breast pain. Other problems which are less likely to be covered by insurance include skin irritation, skeletal deformity, breathing problems, psychological/emotional problems, and interference with normal daily activities. Pre-authorization by the insurance company is required prior to surgery, and the process takes approximately one month. Each insurance policy has different guidelines and exclusions.This procedure is commonly covered by insurance through insurance criteria are becoming more and more restrictive. Although we do not accept insurance, our staff will assist you in obtaining pre-authorization so that you can attempt to be reimbursed for out of pocket expenses

Miguel Delgado, MD · Answer

Unfortunately, insurance companies consider male breast reduction a cosmetic procedure. However there are instances where patients have been able to get their surgery covered. Do your breasts cause you physical and emotional pain? I have a few patients that have succeeded and in particular one Mother who wrote a detailed letter on how she was able to get coverage for her son. You can view the letter on gynecomastia.org, look under Patient Stories for "A Success Story-Start to Finish." Good luck!

Jeffrey Gusenoff, MD · Answer

Gynecomastia just isn't covered by most insurance companies. If you had a hard lump on one side versus the other, or some major psychiatric disorder related to it, that may help, but it is unlikely to get covered. This is usually considered a cosmetic operation, as is breast asymmetry in women.

How can I best argue my case for coverage for male breast reduction surgery to my insurance company?

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