Q: Dr. Eppley, I would like to get a better idea if insurance will cover my gynecomastia reduction procedure. I have had gynecomastia since I was a teen, but it has bothered me enough lately to visit a Doctor. Up until the past few years it has only caused me a little discomfort. I have never been able to sleep on my stomach because of it. Lately I have had occasional pain in my right breast and a sharp pain when bumped into or after exercising, but mainly in my right breast. My Doctor confirmed that I had gynecomastia after a mammogram and x-rays. The radiologist diagnosed it and ruled out cancer. I have fibrous mass centered under my right nipple and smaller nodular lumps on my left side. Really only the right side causes me the most pain. I think insurance should cover it, since I have had the gynecomastia since I was a teen and it is causing me discomfort. I would like to know what if there is any chance that insurance will cover it?
A: Insurance coverage for gynecomastia surgery is a frequently asked question of men considering the surgery. No plastic surgeon can answer that question definitely since your health insurer has their own criteria for coverage and ultimately they have to make that determination based on their criteria…not whether you nor I think it should be covered. This is a process known as predetermination in which the treating doctor submits a letter requesting the surgery, lists the diagnosis and procedure codes and provides pictures of the patient’s chest. From this information, they will make a decision and notify you in writing since you are the subscriber of the policy.
Having said that it is important to know what the criteria are that insurance companies use to make that decision about gynecomastia reduction surgery to see if you have any chance of success. First, the size of the gynecomastia problem must be a grade III or IV in adults based on a well known assessment scale. (yours by the way is a Grade II) Second, you must have had a endocrinological blood panel done to determine if there is any hormonal abnormalities that have not perviously identified and treated. Third, the breast enlargement must pose serious health concerns, such as being a tumor, that has a significant impact on the patient’s health or will so in the foreseeable future.
As you can see, unless there is compelling medical evidence, most insurance companies view most gynecomastia reduction surgeries as a cosmetic procedures and not something that is done to treat a medically necessary condition.
Dr. Barry Eppley