Surgical Management of Gynecomastia: A review of the current insurance coverage criteria
Carly M. Rosen1, Yvonne Rasko, MD1, Sara AlFadil, MD1, Adekunle Elegbede, MD, PhD2, Chinezi Ihenatu1, Arthur Nam, MD2, Sheri Slezak, MD1.
1University of Maryland School of Medicine, Baltimore, MD, USA, 2R Adams Cowley Shock and Trauma Center, Baltimore, MD, USA.
BACKGROUND: Gynecomastia is a common condition affecting males. Depending on the severity and symptom involvement, a patient may choose to undergo surgical excision of the breast tissue. Unlike the policies available for reduction mammoplasty in females, the policies for gynecomastia are variable, incomplete, and not based on strong scientific evidence. This study reviews US insurance company policies for coverage of gynecomastia surgery and compares these policies to the guidelines put forth by the American Society of Plastic Surgeons (ASPS).
METHODS: The top 61 US insurance companies, including Medicare, were selected based on their market shares in 2017. The policy for each company was identified using a web-based search or by contacting the company directly. A systemic review of the policy for each company was performed to gather information regarding coverage criteria. All information gathered was compared to the ASPS recommendations.
RESULTS: In reviewing coverage, 23 of the 61 companies (60 private and Medicare) do not have a well defined policy for management of gynecomastia and assess each request on a case by case basis with no defined criteria. Only 38 of the 61 providers reviewed, have a defined policy, in which they will access each case individually. These companies often require thorough documentation of breast size, BMI, duration of symptoms, prior treatments, and the extent of symptomatic involvement, but requirements vary by company. Many of these policies are limited in their coverage, such that they will cover the excision of tissue but not liposuction. Only 14 companies offer consideration of coverage for patients under 18 years old.
CONCLUSIONS: Coverage of gynecomastia surgical management varies across insurance companies and is often based on internally-generated policies by individual US health insurance companies. 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.
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