Hello Guest

My insurance company's guidelines on gyno

  • 5 Replies
  • 2118 Views
My insurance company's guidelines on gyno
« on: August 02, 2005, 08:13:44 PM »
To put it short - I am pretty poor right now and am looking for insurance to cover my gyno.  Anyway, I asked them about it and this is the info they sent me.  Hopefully this helps some people who are looking for help from an insurance company.

------------------------------------------------------------------
WellPoint Health Networks
Clinical Guidelines
SURGICAL TREATMENT OF GYNECOMASTIA

Specialty: General Surgery
Category: Outpatient Surgical

DEFINITION:
  Gynecomastia is an increase of breast tissue in males.  True gynecomastia consists of proliferation of both ductal and stromal tissue and results from conditions that cause an imbalance in the levels of serum androgens and estorgen, (i.e., either estrogen excess or testosterone deficiency).  Estrogen excess occurs infrequently, as a result of estrogen-secreting tumors.  More commonly, a relative excess of estrogens is present when serum testosterone concentration is reduced.  The testes are the source of virtually all testosterone in plasma.  Thus, disorders that reduce testicular hormone secretion remove the major source of plasma testosterone but have much less effect on circulating estrodial, producing a situation of relative estrogen excess. (1)

During three phases of male life, breast enlargement can be regarded as physiological rather than a pathological event, as follows:
- neonatal gynecomastia (possibly related to the action of maternal and/or placental estrogens);
-adolescent gynecomastia (transient enlargement of the breast is a normal occurrence in male adolescence, usually lasting from 6-18 months);
- gynecomastia of aging (common benign occurence related to decreased levels of plasma testosterone and relative estrogen excess).

Notably, this condition in the older male (age of 60 and beyond) can also be an indication of underlying pathology, (i.e. related to chronic/genetic disorders, medications, etc.).  For this reason, caseful clinical evaluation is warranted to rule out disorders of the cardiovascular system, liver, or other etiologies.  (2)

MEDICAL NECESSITY:
 HPI/PMH:
 Patient is a male without evidence/suspicion of an underlying causative and correctable condition, (e.g., liver disease, testicular malignancy, endocrine disorder, drug induced condition) with pain syndrome that:
  - has a clinically significant impact upon activities of daily living; AND
  - has been refractory to a trial of analgesics or anti-inflammatory agents (for a reasonable time period adequate to assess therapeutic effect); WHEN
  - confirmatory photographs are provided.

MEDICAL ISSUES
  Pain complex necessitate the use of analgesics or anti-inflammatory agents.
 
DIAGNOSTIC TESTING:
  Appropriate diagnostic evaluation has been done for a possible underlying etiology.

SETTING:
  Outpatient

TREATMENT ALTERNATIVES
  Continued conservative treatment (weightloss may be indicated).

ADDITIONAL INFORMATION:
  Physiological gynecomastia usually occurring during adolescence (from approximately ages 10-16) is usually transitory and should be observed for 12-24 months before surgical options are considered.

 Unilateral gynecomastia in post-adolescent age groups may have serious pathological importance.  An evaluation and subsequent excision, when warranted, should be authorized without an observation period.

  The presence of gynecomastia outside the age groups considered possibly physiological, (i.e., neonates, adolescence, old age) warrants clinical evaluation for possible pathological etiology, prior to any surgical interventions.

NOTE:
  Some benefit plans may specifically exclude this service
  Please refer to the member's certificate of coverage for available benefits.
  Some benefit contracts may include a reconstructive benefit which may be applicable.  
  Group specific policy and/or state mandate may supersede this guideline, when applicable.

Linkback: https://www.gynecomastia.org/smf/index.php?topic=2618.0

*

Offline ItsOK

  • **
  • 52
  • Glorp.
Re: My insurance company's guidelines on gyno
« Reply #1 on: August 03, 2005, 04:15:50 AM »
This is good information.

Although this is specific to your particular insurance plan, my impression is that they will cover the surgery for a non-adolescent when it impacts daily life.  They expect the doctors to do reasonalbe prep work to discover whether there's some underlying condition that's causing it.

And if you're still going through puberty, they expect you to wait for a while.  While those of you who are in this position may consider that unduly harsh, it seems medically reasonable to me.

All in all, this looks like a remarkably reasonable and logical coverage guideline.  I wonder how typical it is of the other insurance companies.

*

Offline STILLgotIT

  • ****
  • 466
  • Finally gyne-free
Re: My insurance company's guidelines on gyno
« Reply #2 on: August 03, 2005, 11:09:41 AM »
My insurance company specifically excludes gyne surgery.

Re: My insurance company's guidelines on gyno
« Reply #3 on: August 04, 2005, 11:53:46 AM »
StillgotIT your insurance sounds like mine. They won't cover it no matter what the reason. And will only consider my medical case. What a crock. I just wish our insurance was more like canadas. U.S. insurance will just keep playing around with this condition thinking they know everything even though they could never really understand the truth.

*

Offline STILLgotIT

  • ****
  • 466
  • Finally gyne-free
Re: My insurance company's guidelines on gyno
« Reply #4 on: August 05, 2005, 08:15:05 AM »
Quote
StillgotIT your insurance sounds like mine. They won't cover it no matter what the reason. And will only consider my medical case. What a crock. I just wish our insurance was more like canadas. U.S. insurance will just keep playing around with this condition thinking they know everything even though they could never really understand the truth.



Although it is tempting to wish for a system like Canada's, after careful examination this isn't a great idea.

True, people without money often get treatments that in the US would require money out of pocket. But, the flip side to this is that in other cases people don't get the treatments they desire because of perhaps an extensive cost to a procedure or treatment.

The US system allows for greater advances in science and medicine. This is why we have the greatest treatment in the world. But, with that comes a price.

Plus, in Canada the treatment isn't "free." Canada has some of the highest taxes in the world in order to pay for this "free" medical plan.

When you go and get a "free gyne operation" you are actually receiving a "Canadian subsidized (read: paid for by someone else) operation."

That is hardly fair to the person without gyne who doesn't need an op.

*

Offline Paa_Paw

  • *****
  • 4738
Re: My insurance company's guidelines on gyno
« Reply #5 on: August 06, 2005, 10:56:49 PM »
Photostic,  It sounds like your insurance company has a good, realistic view.  I'll bet that there are many who wish they were as fortunate.

Get the needed medical workup to identify the source and work on the daily living aspects of the issue.

There is some great  information available from the Homepage, including the story related by the mother of a young man and their battle to get his surgery covered.

Good luck.
Grandpa Dan


xx
Notifying Insurance Company ?

Started by mizuno on Gynecomastia Talk

15 Replies
4898 Views
Last post August 17, 2008, 09:35:51 AM
by Grandpa Bambu
xx
My insurance company sucks!

Started by doug1030 on Gynecomastia Talk

3 Replies
1576 Views
Last post November 07, 2005, 03:16:05 PM
by gynosucks1
xx
How to get the Surgery with a reluctant Insurance company.

Started by Paa_Paw on Gynecomastia Talk

0 Replies
219 Views
Last post January 05, 2019, 01:38:41 AM
by Paa_Paw
xx
What does it take for the insurance company to cover "gyne" surgery?

Started by TM on Gynecomastia Talk

5 Replies
3322 Views
Last post September 20, 2007, 08:33:33 AM
by BigLouJr