Gynecomastia is a socially and mentally distressing condition. Up to 20% of males with pubertal gynecomastia suffer from persistent gynecomastia. Although not life-threatening, many men are plagued by their breast fullness – it takes a hefty knock on one’s confidence and self-esteem.
After considering surgery, I’m pretty sure the costs were your next greatest concern. If you have health insurance, you may wonder if and how much of the surgery you can expect your plan to cover. This article will delve into whether insurance covers gynecomastia surgery and the finer details of your health insurance policy to ensure that you aren’t disappointed by a denied claim or surprised by your medical bills.
Definition of Gynecomastia
Gynecomastia, commonly referred to as “man boobs,” is a prevalent condition that causes an increase or overdevelopment in breast gland tissue in boys and men. As a result, their breasts become larger and may even grow unevenly.
Gynecomastia is generally benign (non-cancerous). It is linked to an imbalance between estrogen and androgen hormones. A man’s body typically produces small amounts of estrogen, the hormone responsible for breast growth. However, if his body produces excessive amounts of estrogen or limited testosterone, the breast tissue can start to grow and enlarge.
The condition is most common in teenage boys. However, it can also occur in newborn babies and older men. In other instances, individuals with obesity can develop enlarged breasts. However, this is due to excess fatty tissue and is known as pseudo-gynecomastia.
Gynecomastia can also be caused by other factors, including:
- Medication side effects
- Illegal drugs
- Alcohol misuse
- Health conditions like liver or kidney failure
- Klinefelter syndrome
Gynecomastia isn’t severe, but it can be embarrassing and tough to handle emotionally. Most gynecomastia cases happen during puberty and improve on without treatment within 6 months to 3 years.
However, if gynecomastia is caused by a disease, hormone therapy can be prescribed to treat it. In rare cases, gynecomastia surgery may be required to remove the extra breast tissue.
Overview of Insurance Coverage
Most health insurance plans only provide coverage for “medically-necessary” health-related services.
Medical necessity refers to whether your health plan regards the services, supplies, treatments, and procedures as a necessity to either diagnose or treat the injury or condition or its symptoms.
They typically do not cover cosmetic procedures like Botox, tummy tucks, or breast augmentation. However, certain cosmetic operations are deemed medically necessary when implemented in conjunction with other medical treatments. For example, breast implants after breast cancer surgery.
Insurance plans rely on state and federal health mandates as guidelines to determine which services are medically necessary. Remember that even if your procedure is “covered,” it doesn’t guarantee that your health insurance plan pays for it. You may still need to pay for some of the costs due to co-pay, deductibles, and coinsurance.
Does Insurance Cover Gynecomastia Surgery?
In most cases, gynecomastia surgery is regarded as largely cosmetic and ineligible for insurance coverage. Third-party payments are often declined if there isn’t a medical concern associated with the condition.
However, coverage varies greatly across insurers, and each health plan differs. You will have to talk to your healthcare provider and carefully study your health insurance plan to determine if you are eligible for coverage.
Ask your surgeon for a breakdown of the estimated costs and necessary preparation, care, and supplies. Then, read the Benefits and Coverage Summary you received after enrolling in your insurance plan.
You will also want to discuss cost-sharing, deductibles, and coinsurance with your insurance provider to get an idea of what expenses to expect.
What Types of Insurance Cover Gynecomastia Surgery?
Some health insurance companies willingly cover gynecomastia surgery if it’s medically necessary. Also, insurance policies may cover gynecomastia surgery if glandular breast tissue is the primary cause of gynecomastia instead of fatty deposits.
The American Society of Plastic Surgeons (ASPS) has published a document defining the recommended insurance coverage criteria for reconstructive gynecomastia for physicians and third-party payers.
The ASPS recommends third-party coverage for gynecomastia surgery if:
- The condition reaches more than 1 year after ruling out pathological causes
- The condition reaches grade II, III, or IV
- The condition persists after 6 months with unsuccessful pathological gynecomastia medical treatment
- Pain and discomfort from the increased breast size despite using analgesics
- Persistent gynecomastia despite addressing the underlying cause
However, this isn’t guaranteed. We recommend reviewing your policy to determine if you meet the requirements for coverage. We recommend requesting a copy of ASPS recommended insurance coverage criteria from your physician to submit to your insurer.
Do Different Providers Cover Gynecomastia Surgery Differently?
Eligibility for gynecomastia surgery coverage and the specific costs insurance provides cover varies greatly across companies.
It is critical to confirm with your insurance company what the eligibility requirements are and what they cover once eligible. While some insurers cover the total costs of gynecomastia surgery, others may only offer limited coverage.
For example, some companies only regard patients under 18 years as eligible. And other providers are willing to cover hospital costs and tissue excision but not anesthetics or liposuction.
Factors That Affect Insurance Coverage
While certain medical conditions need to be met to acquire insurance coverage for gynecomastia surgery, different factors like pre-existing conditions, age, and gender also affect the indication of the surgery and the coverage.
Prior to the surgical consult, you should undergo a complete history, physical exam, and diagnostic testing to evaluate the underlying cause of gynecomastia.
Some insurance providers will cover gynecomastia surgery to treat conditions like Klinefelter syndrome, breast cancer, and persistent skin infections and pain that cause physical impairment.
They may also cover surgeries if other non-surgical treatment options have failed in the past. This includes persistent gynecomastia after cessation of certain prescribed and recreational drugs like testosterone, asthma medication, calcium channel blockers, anabolic steroids, and marijuana.
Some health insurance policies only cover gynecomastia surgery for patients under 18 years old.
The patient needs to prove that they are eligible by providing thorough documentation of breast size and body mass index and the extent and duration of their symptoms. They may also be asked to include their prior treatments and proof of discontinuing all supplements and non-prescription drugs known to cause male breast enlargements.
Per definition, gynecomastia is limited to the presence of abnormal breast tissue proliferation in males. The patient needs to be biologically male to gain eligibility for surgery.
Questions to Ask Your Insurance Provider
Before scheduling a gynecomastia surgery, it’s recommended to contact your insurance provider. Ask strategic questions to determine whether your surgery will be covered or not.
If you are eligible for coverage, confirm what type of surgery and how much of the costs the insurance will cover.
Is Gynecomastia Surgery Covered?
Cosmetic surgery for gynecomastia will not be covered. However, some insurance policies cover surgical treatment for reconstructive purposes if the gynecomastia is persistent or other non-surgical treatment options have failed.
It is equally important to check with your service provider to determine if you have the appropriate level of coverage, as policies may vary from fund to fund.
What Type of Surgery is Covered?
Many insurance policies are willing to cover reconstructive gynecomastia surgery.
The surgery involves removing abnormal hypertrophic breast tissue and surrounding subcutaneous tissue to give the breast a more normal masculine appearance. The surgery can require a reduction mammaplasty, subcutaneous mastectomy with skin reduction, or a more extensive mastectomy with assisted lipectomy.
What is the Cost, and How Much Will Insurance Cover?
According to the ASPS, the average cost of gynecomastia surgery is $4,239. However, these costs do not include other related expenses like medical tests, anesthesia, operating room facilities, and prescription for medication.
You should consult your surgeon’s office to calculate the total fee.
You will also need to consult with your insurer to determine what costs they cover. Some insurers cover the total costs of gynecomastia surgery, while others may only offer limited coverage. Ensure you also ask about the co-pay, deductibles, and coinsurance.
Health insurance companies do not cover gynecomastia surgical costs for cosmetic or psychological reasons only. However, some insurance policies cover surgical treatment for reconstructive purposes.
We recommend consulting your doctor and health insurance company to determine if the cost can be covered, including how much of the costs they are willing to cover.