There is a high degree of variability among insurance carriers. I have seen young maies with severe gyencomastia covered and abdomens with heavy pannuses covered. Best to contact your carrier with a good letter detailing your medical issues and a supporting set of standardized photos illustrating your problems.
On What Grounds, Can a Tummy Tuck and a Male Breast Reduction Be Classified As Medical Procedures?
Doctor Answers 7
Different criteria for different insurance carriers
Insurance for gynecomastia and tummy tuck
Until about 10 years ago, insurers would consider payment for gynecomastia surgery. They have implemented more restrictive guidelines and the only basis for coverage would be genetic markers establishing high risk for breast cancer. The code for the surgery is mastectomy for gynecomastia. Barring this, the surgery, whether resection of glandular tissue or liposuction, would be considered cosmetic.
Tummy tuck is also subject to more restrictions. A ventral hernia established by an MRI would be covered but the cost of this is minimal when compared with the tummy tuck. After bariatric surgery, some carriers will cover excision of the panniculus, or hanging apron of abdominal skin, but only upon documentation that rashes have been medically treated and are intractable.
Insurance rarely pays for gynecomastia correction and tummy tucks
If you're inquiring as to how you can get your gynecomastia correction and tummy tuck covered by insurance, this is very difficult to do. Your gynecomastia would have to be from a tumor or trauma as well as the excess skin of your abdomen.
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Insurence and gynecomastia surgery
The best way to find a ground for possible,but not likely, insurance coverage is to go to the official "American society of plastic surgeons" web site. Ask them for "position papers about gynecomastia surgery".Those papers will clarify when one may be eligible for insurance coverage. wikipedia gynecomastia may also give you same clues.
Male breast reductions and tummy tucks--medically necessary?
Usually, male tummy tucks and breast reductions are cosmetic procedures that are not covered by insurance, including when performed after weight loss. If there were severe skin rashes underneath an apron of excess abdominal skin (called a pannus), insurance might cover the excision of the excess skin, but not an entire tummy tuck. Regarding the breast reduction, in my experience the only time this has been covered is in young male patients with a painful localized mass of breast tissue.
Are tummy tucks and male breasts reduction medically necessary?
Tummy Tuck and Male Breast Reduction as Medical Procedures
Both Tummy Tuck and Male Breast Reduction are typically cosmetic (not medically necessary) procedures.
These procedures may become medically indicated (either necessary, recommended, or medically appropriate) when:
- There is significant pain that may be improved, such as with a large hanging area of excess skin
- A hernia or severe loss of support of the abdominal muscles is present
- Excess skin is causing problems with rashes, irritation or infection (or perhaps pain)
- True feminization of the male breast shape that causes significant psychological disturbance
Good News / Bad News
The bad news is that medically indicated does not mean that an insurance company will pay for a procedure (as more often than not they will not pay or reimburse these procedures).
The good news is many people are able to use flexible spending account or health savings account funds for a medically indicated procedure, even when medical insurance does not provide coverage.
Hope this helps,
Nick Slenkovich, MD FACS
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.