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Insurance coverage!

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Insurance coverage!
« on: July 30, 2010, 02:32:00 PM »
Here is my story, which has a very happy ending!

Like pretty much everyone here, I suffered from gynecomastia since age 12-13 or so. Around that age, I noticed that my nipples were getting very swollen and painful. It didn't help that my sister would give me titty twisters a lot. I told my mother, and she took me to the doctor to get them looked at. He dismissed it, saying it was normal for boys my age and that it would resolve itself soon.

Naturally, it didn't resolve itself. I remember going from a happy-go-lucky young kid to a miserable adolescent. I can't blame that entirely on gynecomastia, but it certainly played a part. I didn't want to go to my friend's pool parties or go out on my family's boat for fear of taking off my shirt. I was always in relatively good shape, too, so to have a chest that was flabby and poked out was frustrating and didn't seem fair.

I was never really conscious of the condition in high school...I knew I didn't like having my shirt off but I never really understood why. One day that I will never forget, I was hanging out with some friends around senior year in high school, and one of them pointed at my chest and started laughing. I said what's so funny? He said you're busting out of that shirt man. I looked down and I noticed you could see my puffy nipples poking out under my shirt. That was when I really became aware that I was different than my friends, and that was why I didn't like taking my shirt off.
These same friends called me "beef nipples" a few times too, once in a crowded subway in front of a girl I was hanging out with, which was humiliating and really angered me. Thankfully it was only a couple times though and didn't turn into a nickname or anything.

I started lifting senior year hoping to build up some muscle and get rid of the puffiness. As you all know, that didn't help the problem (maybe even made it worse). I am glad I did start lifting though, as I continued all through college and built up some decent muscle. However it was just all the more frustrating since I had a fit body but still had these puffy nipples sticking out.

In college, I started wondering what was up with my chest and why my nipples were so puffy. I did some research and found this site. Learning more about the condition, I felt around my chest for any lumps or masses, and sure enough there they were. I could grab the hard clumps and feel them in there. I should note - My condition was not a serious case of gynecomastia. You could tell I had it, my nipples protruded an inch or so with ping pong ball sized masses, but it certainly wasn't one of the worst cases. I started reading all of the stories that sounded so similar to my own. This site really is a great avenue for people suffering from this to understand that they are not alone. I read some posts with suggestions of how to conceal the puffy nipples under shirts, and did my best to hide the condition. I still avoided the beach and pools most of the time, and felt uncomfortable when I did go swimming. I remember an ex girlfriend laying in bed with me and playing with my nipples and laughing when they went from puffy to hard, which was a little awkward.

After college I got a decent job, saved up some money and explored the option of surgery. I had a consultation with a well-known gynecomastia surgeon in Massachusetts last April and scheduled a surgery date for last July. In talking with the surgeon, I brought up the possibility that my insurance company would cover the procedure. He said that he would submit it to my insurance company for approval and try his best to get it approved, but that usually his patients had more success filing an appeal after getting denied. I'll get back to that later.
In the months leading up to that surgery date I vowed to try my best to get rid of it myself and do the surgery as a last resort. So I dieted for 3 months and kicked my ass at the gym, went from about 16% body fat to about 10%, and guess what, it didn't help my chest at all. In fact, it actually made it look worse because I had this fit body with this flabby chest.

A couple weeks before my surgery date, I called the surgeon's assistant and asked about the status of insurance coverage. She told me, much to my dismay, that it was denied. However, I knew I would regret backing out of the surgery so I decided to go on with it anyways and pay out of my pocket (almost $6,000). I had the surgery, was overall pretty pleased with the results, and that was that for a couple months.

Then, last September, I got a letter from my insurance company. It said that since my surgeon didn't send over the information they requested 60 days ago, they were denying my coverage. So when I had spoken with my surgeon's assistant before the surgery, she lied to me when she said it was denied! She never sent over information to my insurance company and they denied it two months later because of a lack of info! I was extremely pissed, and filed an appeal with my insurance company. I didn't express my anger to my surgeon and the assistant, though, because I knew I would need their help if I was going to win this appeal.

I called up the surgeon's office and told them I was filing an appeal with my insurance company. The assistant told me she would put together a packet of the necessary information to include in the appeal. I called maybe 4-5 times over the course of a month following up on the status of that packet, and she kept saying she would mail it out soon. Finally I just went over to the office myself to pick it up (over an hour round trip), and hoped that would be the last time I ever had to deal with them.

A month after sending in the appeal, I got a letter back from my insurance company. IT WAS APPROVED!!! I was ecstatic. A short time later I received checks in the mail reimbursing me for the FULL amount of the surgery. They didn't even take out my $500 surgery deductible. So now, I am about 80% improved (still a little bit of asymmetry and a tiny bit of puffiness but it is tons better) and didn't pay a dime.

My advice after this ordeal: DO NOT TRUST YOUR SURGEON. He may say that he is going to help you get the procedure covered by insurance, but there's a good chance that HE WON'T DO SHIT. These guys make much less money on a procedure if an insurance company pays them compared to someone paying out of pocket. Therefore it is actually in their best interest to NOT help you get the procedure covered. Your best bet is to file an appeal after the procedure like I did - that way your surgeon squeezed your pockets for all that you're worth already, and he'll be more willing to help you out.

So, there is hope for insurance coverage, even for people with a relatively minor case like myself! For what it's worth, I have Tufts HMO. This is their policy on Gynecomastia coverage:
Tufts Health Plan may authorize a mastectomy for gynecomastia when one of the following criteria is met:

1.) A separate, discrete mass is present, which is either painful or suspicious for malignancy
2.) Diffuse breast tissue enlargement, without a mass, is causing pain, which is not controllable with non-narcotic analgesics

In cases where the Member is between 15 and 20 years old and the above criteria are not met, the following additional criteria must be met.
- Gynecomastia has been present for at least one year without signs of spontaneous involution and must be Grade III or Grade IV as defined above
- The Member must have a Body Mass Index, BMI, less than the 95th percentile for age

I was 24 when I had the surgery, so the second part didn't apply to me. When filing my appeal, I focused on the first point. I had a separate discrete mass, and it was painful (at times). After getting supporting statements from my surgeon, it was approved.
I hope my story gave some people considering surgery hope that they too will be covered. What I did was risky for someone without some savings, though, since there was a good chance I was going to be on the hook for the surgery. In fact, I had accepted that I was down 6 grand until I received that letter in September.

I attached before and after pics.
The "before" is with nipples hard, looking their very best. When they were soft, they poked out much more.
The "after" is almost a year after surgery (nipples hard)

Linkback: https://www.gynecomastia.org/smf/index.php?topic=21222.0

Re: Insurance coverage!
« Reply #1 on: July 31, 2010, 06:40:44 PM »
Congratulations on your surgery and also on your perseverance.

Insurance companies are loathe to cover gyne surgery -- but once in a while (and you are that "once") they will cover.

It is best to inquire of your insurance company about their exact requirements for coverage of gyne surgery -- in advance of your surgery.  Then discuss it with your surgeon.  Many times the surgeon may not accept insurance but will cooperate in providing information and a claim to your insurance company.

Dr Jacobs
Dr. Jacobs 
Certified: American Board of Plastic Surgery
Fellow: American College of Surgeons
Practice sub-specialty in Gynecomastia Surgery
815 Park Avenue
New York, New York 10021
Telephone:  (212) 570-6080
Email:  dr.j@elliotjacobsmd.com
Website:  http://www.gynecomastiasurgery.com
Website:  http://www.gynecomastianewyork.com/revi

Re: Insurance coverage!
« Reply #2 on: August 01, 2010, 01:12:51 AM »
Thank you Dr. Jacobs. I wanted to let you know that I lurked this forum for a few years leading up to my surgery, and I always found your posts extremely insightful and helpful. Keep it up - you may be helping a lot more people than you think.

Re: Insurance coverage!
« Reply #3 on: August 01, 2010, 07:20:35 AM »
Thanks!  Your kind words are most appreciated.

Dr Jacobs

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