This is my second blog in this series on gynecomastia. I have seen a bunch of young men recently who are plagued by breast fullness. They won’t take off their tops at the pool or in school locker rooms. They layer their clothing. It is something we don’t talk about a lot, but when boys and men develop breasts, it can be socially and mentally distressing.
So, you are a boy or man with breasts. Man breasts. Moobs. Whatever you want to call them. The question is, will insurance cover their removal?
First, let me say we as the plastic surgeons do not make this call. We get how gynecomastia is distressing. We understand what an impact it can have. Insurance companies will not cover gynecomastia surgery for emotional reasons only, and they will not cover gynecomastia when it is not true gynecomastia (ie it needs to be actual breast tissue, not fat). If chest enlargement is due to fat, it is not true gynecomastia, and it can be treated by simple liposuction. If it has true breast tissue, there will be a surgical component where the breast tissue is cut out.
As one plan states in bold,
“xx HealthCare does not cover suction lipectomy or ultrasonically assisted suction lipectomy (liposuction) as a sole method of treatment for gynecomastia, because such treatment is considered unproven in the treatment of gynecomastia.”
“It does not cover surgical treatment of gynecomastia under EITHER of the following conditions, as it considered cosmetic in nature and not medically necessary: 1. when performed solely to improve appearance of the male breast or to alter contours of the breast wall and 2. when performed solely to treat psychological or psychosocial complaints.”
And every plan is different even within an insurance company. So you need to look up YOUR plan and see what it says. I recently did this surgery on a teenager who was part of 2 insurance plans. One plan’s gynecomastia section simply said, “not covered.” The other plan did cover it.
What gets it covered?
- Puberty /adolescent onset gynecomastia which has persisted for 2 years and meets ALL of the following criteria
- grade II, III, IV
- associated with breast pain, despite use of analgesics
- the use of gynecomastia inducing drugs has been discontinued for at least one year
- gynecomastia persists despite correction of underlying causes
- hormonal causes have been excluded
- photos front and side have been submitted
- Klinefelter syndrome
- Some require it is nontender; some require preop tests like mammogram or ultrasound to confirm it is breast tissue; some require labs for hormones have been done (like estridiol, LH, and testosterone; and some require the tissue be sent to pathology to confirm there was breast tissue (not just fat)
Remember to look up your plan. And if it looks promising, see a plastic surgeon who can help see if you can preauthorize a surgery.