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Company logo: Elliot W. Jacobs, MD, FACS - Diplomate, American Board Of Plastic Surgery

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Can Insurance Coverage for Gynecomastia Be a Bad Thing?

gynecomastia new york

We have many discussions with our New York gynecomastia patients about the frustrations of trying to get insurance coverage for male breast reduction.  Sadly, insurance companies consider the procedure cosmetic, no matter how much anguish a man may be suffering, and they generally won’t pay for surgery.

That’s why it was unusual to have a conversation with a man recently on gynecomastia.org about why the availability of coverage might not be good.  Here’s the way the interaction went.

The gentleman wrote in one of the site’s forums saying that a plastic surgeon he consulted said the procedure is sometimes covered–which we might say at our most optimistic–while another doctor said it is “almost always” covered.  This latter view has not been our experience.

Lucky patient, right?

Maybe not.  We wrote back to contribute our views, as did other board certified plastic surgeons.  One had an interesting thought: maybe the “almost always” doctor doesn’t have enough experience with man boobs to know that the surgery is not usually covered.  This same surgeon noted that the procedure used to be covered more often than it is today.

We explained to the prospective patient that some insurance companies will pay if breast tissue is removed with a scalpel only.  So, if a plastic surgeon uses liposuction during the procedure at all, whether removing breast gland–which we routinely do with our specially designed liposuction instruments–or fat, coverage is denied.  It’s as if the word “liposuction” is a red flag that automatically triggers claim rejection.

This is very unfortunate, and not just because these organizations have such a narrow understanding of the power and versatility of liposuction.  We fear that it may drive patients to opt for scalpel-only surgery, when liposuction is needed in virtually all cases to sculpt smooth contours.  (In fact, scalpel-only surgery can easily result in a crater deformity in which part of the breast ends up looking sunken–anything but the natural result patients hope for.)

This happened to be the case for the man seeking advice.  He wrote in later that he had verified that his carrier would only cover the procedure if a scalpel were used (not liposuction).  One might then wonder what his two doctors had in mind for the procedure and for the official operative report.  While we are not in the habit of questioning the strategies of other plastic surgeons, we feel that’s exactly why a patient should be as informed as possible and have a 100% clear understanding of the surgical plan in all its dimensions.

One more thing about insurance: even when a patient receives a green light from their carrier, the ultimate claim can still be rejected.  One highly experienced surgeon member of gynecomastia.org advised that letters from these companies often include a statement to this effect: “Prior authorization does not guarantee payment.”  It is a rude shock indeed to go through surgery believing you have coverage, then be hit with a surprise bill.

When dealing with insurance coverage for gynecomastia, the old adage comes to mind: hope for the best but prepare for the worst.

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