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Access to Surgical Treatment of Adolescent Gynecomastia: Characterizing Insurance Barriers and Preauthorization Denial Rates
Linda M. Saikali
*, Anish Raman, Leigh Friedman, Gerardo Perla, Shailee Shroff, Jacob R. Thomas, Cassandra A. Ligh
Children's Hospital of Philadelphia, Philadelphia, PA
Background: Insurance coverage for surgical correction of adolescent gynecomastia remains highly variable. This study defines the rate of preauthorization denials and identifies patient and payer characteristics associated with denials. Secondary objectives include quantifying treatment rates among those denied coverage and characterizing reasons for denials
.Methods: A retrospective review was performed of all pediatric patients evaluated for gynecomastia at the Children's Hospital of Philadelphia between Jan. 2011 and Jun. 2024. Demographic, clinical, insurance, and preauthorization data were collected. Multivariable logistic regression was used to identify predictive factors for denial and out-of-pocket payment.
Results: Among 360 patients, the mean age at the first visit was 16.3 years (SD 2.0), with a mean gynecomastia duration of 4.1 years (SD 2.7). Most had Grade 2 (n=146, 40.8%) or 3 (n=104, 29.1%) gynecomastia. Of the 282 patients (78.3%) who pursued treatment, 66 (23.4%) received preauthorization from their primary insurance, 11 (3.9%) were approved through secondary coverage, and 205 (72.7%) were denied or offered out-of-pocket pricing. Denials often resulted from contract exclusions due to cosmetic classification (n=99, 45.8%); however, 31 denials (14.4%) cited insufficient documentation. Factors predictive of approval included unilateral breast growth (OR 4.4, p=0.02), Medicaid/CHIP coverage (OR 42.1, p<0.001), or United Healthcare coverage (OR 20.3, p=0.03). Of the 207 patients (57.5%) who underwent procedures, 126 (60.9%) paid out-of-pocket, with 79.4% of these opting for lower-cost adult facilities. Black patients (OR 0.3, p<0.01) were less likely to self-pay; those of non-Hispanic/LatinX ethnicity were more likely (OR 5.2, p=0.045).
Conclusion: This study underscores the substantial insurance barriers to surgery for adolescent gynecomastia and the effect of coverage exclusions on treatment pathways. The high reliance on out-of-pocket payments and the disparities in self-pay rates highlight the need to address systemic inequities in surgical access.
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