Gynecomastia and Insurance Coverage
One of the recurring questions we field from New York gynecomastia patients is about insurance coverage. The unfortunate truth is that most insurance companies will not pay for even part of male breast reduction.
Here’s the rationale:
Insurance carriers view gynecomastia surgery as a cosmetic procedure. Even when the condition is pronounced, most cases can’t qualify for “reconstructive” surgery. Were a company to pay for a procedure seen as cosmetic, it would open the door to thousands of requests for coverage of male breast reduction and many other elective surgeries.
What’s more, it doesn’t matter whether a man suffers extreme anguish over his condition. Here is part of a paragraph from the guidelines of one insurance carrier:
Medical treatments and surgery to alter a perceived abnormal appearance, or for psychological reasons, are considered cosmetic and are not covered. The fact that a Covered Person may suffer psychological consequences or socially avoidant behavior as a result of benign gynecomastia does not classify surgery (or other procedures done to relieve such consequences or behavior) as a reconstructive procedure.
So, are men ever successful with claims? Occasionally. Chances for success vary from carrier to carrier, of course, and we advise our New York gynecomastia patients to investigate this thoroughly before committing to surgery.
In the case of the carrier above, cases involving pain and “functional deficit” (meaning the patient suffers loss of function, not including the inability to compete in sports) are the only ones worthy of consideration.
In addition, the company requires a long list of tests and proofs that are unlikely to be covered by insurance. One is especially problematic: proof that the underlying cause of gynecomastia is breast gland, not fat. In reality, both types of tissue are always present. Read more about these and other gynecomastia issues in our blog dedicated to the topic.
It’s no wonder so few men are successful in getting their insurance provider to cover male breast reduction. The situation can be very frustrating for our patients. Whether and how to approach an insurance company and other options for payment are subjects we cover in consultation: contact us at 212-570-6080.
