Yes, health insurance may cover gynecomastia surgery, but it depends on several factors, including:
- The terms of your specific health insurance plan
- The reason for the surgery (e.g., medical necessity vs. cosmetic reasons)
- Your age and gender
- The severity of your gynecomastia
Most health insurance plans will only cover gynecomastia surgery if it is deemed medically necessary. This means that the surgery must be performed to treat a physical condition or to improve your quality of life. For example, if your gynecomastia is causing you pain, difficulty exercising, or emotional distress, your health insurance plan may cover the surgery.
However, if the surgery is being performed solely for cosmetic reasons, such as to improve your appearance, your health insurance plan is unlikely to cover it.
Understanding Gynecomastia and Gynecomastia Surgery
What is Gynecomastia?
Gynecomastia is a condition that causes abnormal enlargement of breast tissue in men. It can affect one or both breasts, and it can be uneven or symmetrical. Gynecomastia is not the same as pseudo gynecomastia, which is excess fat in the chest area without glandular tissue growth. Gynecomastia can be caused by various factors, such as hormonal changes, medications, diseases, tumors, or genetic disorders. Gynecomastia can occur at any age, but it is most common during puberty and old age. Gynecomastia can cause physical discomfort, emotional distress, and low self-esteem in men who have it.
What is Gynecomastia Surgery?
Gynecomastia surgery, also known as male breast reduction or reduction mammaplasty, is a surgical procedure that removes excess breast tissue and fat from the chest area. The goal of gynecomastia surgery is to restore a more masculine and contoured chest appearance. Gynecomastia surgery can be performed using different techniques, such as liposuction, excision, or a combination of both. Liposuction involves inserting a thin tube through small incisions and suctioning out the excess fat. Excision involves cutting out the excess glandular tissue and skin with a scalpel. Sometimes, the areola (the dark skin around the nipple) may also need to be resized or repositioned. Gynecomastia surgery is usually done under general anesthesia or local anesthesia with sedation.
Factors that Determine Insurance Coverage for Gynecomastia Surgery
Insurance coverage for gynecomastia surgery is not guaranteed and depends on several factors. Some of these factors are:
- Severity of chest pain: Some men with gynecomastia may experience chest pain or tenderness due to the enlarged breast tissue. This can interfere with their daily activities and quality of life. If chest pain is severe and persistent, it may be considered a medical necessity for gynecomastia surgery.
- Persistence after stopping certain medications: Some medications can cause gynecomastia as a side effect. These include steroids, anti-androgens, anti-depressants, anti-psychotics, and some drugs for heart disease or prostate cancer. If gynecomastia persists after stopping these medications for at least six months, it may be considered a medical necessity for gynecomastia surgery.
- Duration of condition: Some cases of gynecomastia may resolve on their own over time, especially if they are related to puberty or hormonal changes. However, some cases may be chronic and last for more than two years without improvement. If gynecomastia is long-standing and does not respond to conservative treatments such as weight loss or medication adjustment, it may be considered a medical necessity for gynecomastia surgery.
- Other medical factors: Some medical conditions or diseases can cause or worsen gynecomastia. These include liver disease, kidney disease, thyroid disease, testicular cancer, breast cancer, Klinefelter syndrome, or other genetic disorders. If gynecomastia is associated with any of these conditions or diseases, it may be considered a medical necessity for gynecomastia surgery.
Can Gynecomastia Surgery Be Covered by Insurance?
Insurance coverage for gynecomastia surgery is not guaranteed and varies depending on the insurance company and policy. Some insurance companies may consider gynecomastia surgery as cosmetic and not cover it at all. Others may consider it as reconstructive and cover it partially or fully if certain criteria are met.
Exploring Insurance Coverage Options
The best way to find out if your insurance covers gynecomastia surgery is to contact your insurance company directly and ask them about their policy and requirements. You may need to provide them with information such as your diagnosis code (ICD-10 code), your procedure code (CPT code), your surgeon’s name and credentials, your estimated cost of surgery, and your medical records and documentation. You may also need to obtain a pre-authorization or a pre-determination letter from your insurance company before you schedule your surgery. This letter will state whether your insurance company approves or denies your request for coverage and the amount of coverage they will provide.
How to Get Gynecomastia Surgery Covered?
If your insurance company denies your request for coverage or provides insufficient coverage, you may have some options to appeal their decision or negotiate a better deal. Some of these options are:
- Request a peer-to-peer review: This is a process where your surgeon can talk to a medical reviewer from your insurance company and explain why gynecomastia surgery is medically necessary for you. Your surgeon can provide evidence and arguments to support your case and try to persuade the reviewer to approve your request for coverage.
- Request an external review: This is a process where you can ask an independent third-party organization to review your case and make a decision. The external reviewer will be a qualified medical expert who is not affiliated with your insurance company. You can request an external review if you have exhausted all the internal appeals with your insurance company or if you are dissatisfied with their decision.
- Negotiate a discount or a payment plan: If your insurance company does not cover gynecomastia surgery or covers only a small portion of it, you may be able to negotiate a lower price or a payment plan with your surgeon or the hospital. You can ask them if they offer any discounts for paying in cash, paying upfront, or paying in installments. You can also ask them if they have any financial assistance programs or charity care options for patients who cannot afford the full cost of surgery.
What to Consider When Evaluating the Cost of Gynecomastia Surgery?
The cost of gynecomastia surgery can vary widely depending on several factors, such as the surgeon’s experience and reputation, the geographic location, the type and extent of surgery, the type and duration of anesthesia, and the facility fees. The average cost of gynecomastia surgery in the United States was $4,123 in 2019, according to the American Society of Plastic Surgeons. However, this figure does not include other costs that may be involved in gynecomastia surgery, such as:
- Anesthesia fees: These are the fees charged by the anesthesiologist or the nurse anesthetist who administers the anesthesia during surgery. Anesthesia fees can range from $600 to $1,500 depending on the type and duration of anesthesia.
- Surgeon’s fees: These are the fees charged by the plastic surgeon who performs the gynecomastia surgery. The surgeon’s fees can vary widely depending on the surgeon’s experience, reputation, and skill level. A surgeon’s fees can range from $2,000 to $8,000 depending on the type and extent of surgery.
- Post-surgery costs: These are the costs that may be incurred after the gynecomastia surgery, such as medications, compression garments, follow-up visits, lab tests, and possible complications. Post-surgery costs can range from $200 to $2,000 depending on the individual case.
- Financing options: If you cannot afford to pay for gynecomastia surgery out of pocket or with insurance, you may consider some financing options that can help you cover the cost of surgery over time. Some financing options include medical credit cards, personal loans, health savings accounts (HSAs), flexible spending accounts (FSAs), or crowdfunding platforms.