Q: My 14 year-old son has developed breast enlargement that is quite troubling to him. Do you know if insurance will cover gynecomastia surgery?
A: There is no way to predict whether any insurance company will or will not cover an adolecent’s gynecomastia surgery. I have seen numerous cases over the years that has been covered (most before 2000) and many (since 2000) that has not. Regardless of what an insurance company may say in its declaration of coverages or what may be spoken on the phone by their representatives, nothing is certain unless it appears in writing. Therefore, pursuit of insurance coverage must be qualified with a predetermination process. This is essentially a letter from a plastic surgeon stating the diagnosis and intended surgery, complete with photographs of the patient’s chest. In addition for gynecomastia determination, it is important to have an endocrinologic work-up which demonstrates that there is not an hormonal basis for the gynecomastia which could be treated and reversed by medical treatments and thus not needing surgery. Even with this approach, there is at best a 50:50 chance. If the photographs do not show a significant breast mound (like a woman’s breast) those chances drop significantly. Only the most severe gynecomastias would be likely to be covered, anything less will be judged to be just a cosmetic gynecomastia surgery problem.
Dr. Barry Eppley