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Surgical Management of Gynecomastia

A Review of the Current Insurance Coverage Criteria

Rasko, Yvonne M., M.D.; Rosen, Carly, B.S.; Ngaage, Ledibabari M., M.A. Cantab., M.B. B.Chir.; AlFadil, Sara, M.D.; Elegbede, Adekunle, M.D., Ph.D.; Ihenatu, Chinezi, B.S.; Nam, Arthur J., M.D.; Slezak, Sheri, M.D.

Plastic and Reconstructive Surgery: May 2019 - Volume 143 - Issue 5 - p 1361–1368
doi: 10.1097/PRS.0000000000005526
Cosmetic: Original Articles
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Background: Gynecomastia is a common condition that can be corrected with surgical excision of the breast tissue. Unlike the policies available for reduction mammaplasty in women, gynecomastia policies are variable and not based on strong scientific evidence. This study reviews U.S. insurance policies for coverage of gynecomastia surgery and compares these policies to the guidelines put forth by the American Society of Plastic Surgeons.

Methods: Sixty U.S. insurance companies were selected based on their market share value. Medicare was also evaluated. The policy for each company was identified using a Web-based search or by contacting the company directly. Policies were reviewed to abstract coverage criteria. All information gathered was compared to national recommendations.

Results: Of the 61 companies evaluated, 38% did not have a well-defined policy for gynecomastia surgery and assessed each request on a case-by-case basis with no defined criteria. The remaining 62% of providers held a defined policy. Companies often required thorough documentation of breast size, body mass index, extent and duration of symptoms, and prior treatments, but requirements varied between insurers. Many of these policies were limited in their coverage, e.g. they would cover tissue excision but not liposuction. Fourteen companies would consider of coverage for patients younger than 18 years.

Conclusions: Coverage of gynecomastia surgery varies across insurers. Insurance company considerations do not often align with patient concerns and physician recommendations on gynecomastia and its treatment options. Coverage criteria should be reevaluated and universally established, to expand access to care and improve treatment efficiency.

Baltimore, Md.

From the Department of Plastic Surgery, University of Maryland Medical Center; and the Department of Plastic and Reconstructive Surgery, R Adams Cowley Shock Trauma Center.

Received for publication July 2, 2018; accepted November 20, 2018.

Disclosure:The authors have no financial interest to declare in relation to the content of this article. No funding was received for this article.

Yvonne M. Rasko, M.D., Department of Plastic Surgery, University of Maryland, 22 South Greene Street, Baltimore, Md. 21230, yrasko@som.umaryland.edu, Instagram: @dr_millie_n

©2019American Society of Plastic Surgeons