Gynecomastia Surgery: What Health Plans Want
With so much news about reforming the U.S. health care system, I could not help but think of the letters I have from various health insurance firms telling what evidence they need to see to approve a teen or man’s male breast reduction surgery.
Paperwork!
I think you’ll agree it’s a scattershot approach.
Here’s one from Harvard Pilgrim Health Care
Company policy:
- Covers those 16 and over
- Must have a gynecomastia diagnosis after a physical
- Signs and symptoms have persisted for at least 12 months despite
treatment of any underlying cause.
- Must be followed by an MD for at least 12 months
Documentation required:
- Medical records of the presence, extent and duration of gynecomastia
- Pre-operative photos
- Medical history including pharmacy records, chromosome analysis and drug screens.
- Proof of specialist care by a surgeon or endocrinologist to i.d. and treat any underlying condition.
(A chromosome test reveals if the patient has any genetic illness that causes gynecomastia. Hence, the need for an endocrinologist who also tests the patient to see if hormones are responsible.)
Reasons to go ahead with the gynecomastia plastic surgery:
- A dominant breast mass
- Gynecomastia on both sides
- Non-reversible gynecomastia due to medications prescribed to treat a medical condition or illness.
- Klinefelter’s Syndrome
- Grade III or IV gynecomastia for at least a year.
Exclusions:
- Under age 16
- Drug screen evidence of substance abuse
- BMI greater than 30, indicating obesity
The primary reason for granting coverage for surgery is psychological distress.
Nonetheless, most health plans contain a Catch-22 clause that specifically excludes any cosmetic treatments (like male breast reduction) that:
- Improves appearance
- Is performed for psycho-social reasons
Next: Many experts have put their heads together and recommended a common sense checklist for granting gynecomastia surgery.
That suggested checklist also screens for other reasons – like street drugs – that a may cause gynecomastia.
It also considers the psychological and physical damage that happens over time to a guy with man boobs.