DOES INSURANCE COVER GYNECOMASTIA SURGERY

Gynecomastia (or gyno) is a medical condition suffered by many men each year. This term describes the condition of swollen and enlarged male breast tissue, typically caused by a hormonal imbalance.

If the swelling caused by the gynecomastia is especially pronounced and obvious, it can lead to a loss of self-esteem and feelings of inadequacy. In some cases, this condition can lead to extreme pain and a loss of some functional ability.

Moreover, in a relatively small subset of cases, there may a deeper physiological problem – such as the existence of a cancerous tumor within the breast area – that poses a direct health risk. This is when gynecomastia surgery becomes an important option.

Most insurance companies will not provide coverage for this medical condition, except in conditions where there are life-threatening health problems.

Thus, the starting point for getting gynecomastia surgery insurance coverage is being able to prove that your condition requires immediate medical attention. This may require asking your doctors if and when you can qualify for coverage.

What is gynecomastia?

To understand why insurance coverage is not always available, you first have to understand what gynecomastia is and how it appears in some men. This is a relatively common condition that results in over 200,000 cases per year.

The swelling of the breast tissue, especially the tender area surrounding the nipple, is caused by an imbalance between the male hormone testosterone and the female hormone estrogen.

There are several potential reasons for this imbalance: puberty, aging, medications, and health conditions that affect these hormones (e.g. kidney disease, liver failure, hyperthyroidism, hypogonadism).

Gynecomastia can be sub-divided into one of four different grades, ranging in severity from Grade I (not severe) to Grade IV (very severe):

  • Grade I – minor enlargement, no excess skin
  • Grade II – moderate enlargement, no excess skin
  • Grade III – moderate enlargement, excess skin
  • Grade IV – marked enlargement, excess skin

To qualify for insurance coverage and receive payment for any medical procedures via gynecomastia insurance providers, you will typically need to prove that you have Grade IV gynecomastia.
gynecomastia-grades

Is gynecomastia surgery covered by insurance?

Unless you are suffering from extreme pain or there is evidence of a cancerous tumor growing in your chest area, gynecomastia surgery is considered cosmetic surgery and is therefore not covered by insurance companies.

They simply will not pay under their coverage terms. Highlighting the “psychological benefits” of having your swollen chest area reduced in size will typically not be enough to receive coverage for the procedure.

In short, insurance companies view gynecomastia surgery the same way that they view other types of cosmetic surgery, such as having wrinkles removed from your face.

Pros and cons of gynecomastia surgery

There are a number of clear advantages of gynecomastia surgery if you can receive coverage. One of these is that this medical procedure is 100% guaranteed to get rid of the gynecomastia. Moreover, since it is in part a cosmetic procedure, it is also a very personalized and customized procedure.

You will know exactly what you will look like after the surgery, and you will have a real boost in self-confidence after the surgery.

However, there are also disadvantages. One of these, obviously, is that the surgeon will need to cut into your breast tissue and remove part of the swollen area. This requires making incisions on your body, which could leave bruises or scarring.

You will also need to receive anesthesia for this procedure, which also introduces some risks. And the post-surgery recovery process can be very painful in the first few weeks. You may experience a lot of pain around your chest area.

Surgery options covered by gyno insurance

The surgical removal of male breast tissue can include any of these four options:

  • Subcutaneous mastectomy
  • Liposuction-assisted mastectomy
  • Laser-assisted liposuction
  • Laser-lipolysis without liposuction

Each of these surgical procedures will differ in terms of costs and coverage provided.

Costs of gyno surgery: Will your insurance company pay?

Paying for gynecomastia surgery and other gyno procedures is a very real concern.

As a rule of thumb, the cost of gynecomastia surgery in the United States can cost as much as $10,000, with most surgeries in the range of $6,000-$8,500.

The relative cost of the procedure depends on the severity of your condition, as well as the skill and experience of your surgeon and the facility where you are having the work performed. The payment for the procedure can be broken down in the following way:

  • Surgeon Fees: $4,000 – $4,500
  • Anesthesiologist: $1,500 – $2,000
  • Lab tests: $500 – $1,000
  • Post-surgery procedures (especially if there are complications): $100-$500

Given the relatively high cost of the procedure, it’s easy to see why many individuals would prefer to have their insurance provider cover the costs and pay for the procedure.

Important criteria: How to get your insurance to pay

While the exact terms of coverage can vary greatly between insurance providers, the following three criteria are generally universal. If you would like your insurance carrier to cover the costs, you will need to meet these three criteria:

  • You have a well-defined physical or physiological problem resulting in a medical condition that requires immediate attention;
  • This problem or abnormality has resulted in a specific functional problem, such as the inability to perform at work;
  • This functional problem is recurrent and persistent. In other words, the problem must be more than just not being able to go into the workplace one time – there has to be a pattern of this happening over an extended period of time.

If you do not meet all three of these criteria, your chances of getting full insurance coverage for gynecomastia surgery are greatly reduced. In that case, you will need to talk to your doctor, who may be able to discuss your specific case with the insurance company, as well as provide extensive lab tests and results documenting the extent of your problem.

Automatic approvals

While there is no such thing as a 100% guarantee, it is a virtual certainty that you will be automatically approved if you have a cancerous tumor developing in your breast area and it is causing a life-threatening condition. However, breast cancer is very rare in males, so it is difficult to qualify.

In all other cases, though, the insurance company will likely require extensive medical proof – such as documented medical visits and lab tests – before they authorize coverage.

The problem, from their perspective, is that some cases of gynecomastia are actually cases of pseudogynecomastia caused by improper diet or lack of exercise.

Insurance carriers that will cover gynecomastia surgery

Terms of coverage can vary widely on a state-by-state basis, so always be sure to check the fine print of your insurance policy. The following large insurance companies are known to provide some coverage, if limited, for gynecomastia surgery:

  • Aetna
  • Blue Cross and Blue Shield
  • CIGNA
  • Humana
  • United Health Care

There are also smaller insurance carriers that might provide coverage and make payments on your behalf. As with filing any insurance claim, there are certain steps that you will need to take to guarantee coverage and payment.

For example, always keep copies of lab tests and medical evaluations. If you are taking certain medications, keep records of those as well. And be sure to submit all paperwork in a timely manner when required. This will speed up the processing of your claim.

Alternatives to gyno surgery

You do have a few alternatives if you do not receive coverage:

  • Weight-training exercise that specifically targets chest area
  • Cardio exercise for slimming and sculpting
  • Nutritional supplements or medications
  • Change of diet to reduce fat and carbohydrates

It is known that medications, such as some antibiotics and anti-anxiety medicines, can cause swelling of the male breast tissue.

Thus, one option would be to simply stop taking these medications. In other cases, though, this may be impossible, such as if you are taking AIDS medicines or medications related to chemotherapy.

Moreover, it is known that some illegal substances – such as anabolic steroids – can cause the appearance of gynecomastia. So cutting back or discontinuing these substances could have a marked effect on your outward appearance.

That’s because steroids are known to change the body’s natural hormonal balance.

Since gynecomastia is a relatively common problem, there are alternatives that are common and straightforward and only minimally expensive. Moreover, they do not require going under the knife, as you would with a complex surgical procedure.

Conclusion

In order to qualify for gynecomastia surgery insurance, you must be able to prove a serious and life-threatening condition, such as the existence of a cancerous tumor growth. If you are unable to prove this, “psychological trauma,” no matter how severe, is very unlikely to sway the opinion of the insurance provider.

Even claims of “severe pain” may not be enough. That’s because gynecomastia, while an embarrassing condition, is generally not debilitating on a regular, recurring and persistent basis.

The good news is that there are a growing number of surgical options if the enlargement of the breast tissue becomes very marked and noticeable. By working closely with your doctor, you may be able to provide the medical basis to have your insurance carrier cover your surgery.

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