Gynecomastia Medically Necessary
Male, 33 living with gynecomastia since adolescence. I’ve reached out to my insurance company and they provided me with this guide attached explaining what would make the procedure “medically necessary” so I could get this covered.
Mastectomy or reduction mammoplasty for the surgical treatment of gynecomastia is considered medically necessary for EITHER of the following conditions:
• Klinefelter syndrome (which I’ve already been tested for)
• Either pubertal (adolescent) onset gynecomastia that has persisted for at least two years OR post pubertal-onset gynecomastia that has persisted for one year, when ALL of the
following criteria are met:
-Glandular breast tissue confirming true gynecomastia is documented on physical exam and/or mammography.
-The gynecomastia is classified as Grade II, III or IV per the American Society of Plastic Surgeons classification. (I’d say I’m around grade III)
Preoperative frontal and lateral photographs confirm the presence of at least Grade II gynecomastia.
The condition is associated with persistent breast pain, despite the use of analgesics.
The use of potential gynecomastia-inducing drugs and substances has been identified and discontinued for at least one year, when medically appropriate.
The gynecomastia persists, despite correction of any underlying causes.
Hormonal causes, including hyperthyroidism, estrogen excess, hyperprolactinemia and hypogonadism have been excluded by appropriate laboratory testing (e.g., with levels of thyroid stimulating hormone [TSH], estradiol, prolactin, testosterone and/or luteinizing hormone [LH]) and, if present, have been treated for at least 12 months before surgery has been considered.
I essentially meet every requirement. I’m being treated for my thyroid problems and testosterone problems for over 2 years now. No matter how much weight I lose my breasts stay the same. I’ve been dealing with this for over a decade. I feel them and they feel like true gyno, and they hurt and cause me back and neck problems. Not to mention the the body dysmorphia being a cis-gendered man rocking a B-cup. I know it’s unlikely for this to go through, but I’ve already met my out of pocket max and if I could get this covered that would be such a weight off my chest (literally).
I’ve already seen my PCP regarding this and they referred me to a plastic surgeon who then in turn told me to ask my PCP for a prior authorization before anything else. My question is who is the right doctor to ask for the prior authorization? I want to get this process going, so should I reach out to other surgeons within my network as well?
