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Insurance company ordered to pay for surgery
Insurer claimed gynecomastia case was cosmetic
An insurance company has been ordered to reimburse a father for his teenage son's gynecomastia surgery after it had refused on the grounds that it was a cosmetic procedure.1
The decision went all the way to the New York Supreme Court's Appellate Division.
Group Health Inc. (GHI) was ordered to pay for the surgery because it was 'medically necessary' for the boy to lead a normal life, the court says. GHI was ordered to pay $5,000 to the father, who had already paid for the surgery that cost $7,500.
"This would be one of the few cases of gynecomastia that has been covered in the last few years," says Larry Pinkner, MD, plastic surgeon and owner of SurgiCenter of Baltimore and past president of the American Association of Ambulatory Surgery Centers.
The father sued GHI in 2004, when the boy was 17. According to legal documents, the teen was teased by his peers and refused to attend an out-of-state university because he was afraid that students in his dormitory would ridicule him.1 In an unanimous decision, the appellate division judges rejected the insurer's argument that the plaintiff did not suffer emotional turmoil. The judges said, in fact, that ''the patient suffers 'depression' and 'emotional distress' from this condition.'' The judge in the original case, Manhattan Civil Court Judge Barbara Jaffe, said in 2004 that the boy was unable to function as a normal teen because of the condition. She said it was ''an objective, tangible and unusual source of turmoil, more akin to a clubfoot or cleft palate than to a large nose, heavy acne or diminutive breasts on an adolescent female, all of which are relatively common.''1
This case illustrates a long-standing debate between surgeons and the insurance industry over what exactly is "cosmetic" and what is "reconstructive." For Walter L. Erhardt Jr., MD, FACS, past president of the American Society of Plastic Surgeons and chair of the society's Public Education Committee, the distinction is clear: "Cosmetic surgery is designed so that you're taking something in the realm of what a prudent person would say is normal and you try to improve on it because the patient wants to do it electively," Reconstructive surgery is taking something the prudent observer would say is not within the realm of normal and you try to get it closer to normal."
Within the last five years, Erhardt has seen a significant change by insurance companies on what procedures they are willing to cover.
The simplest way to avoid having to review a procedure is simply to exclude it, "and that seems to be the approach that's become more and more popular with the insurance industry," Erhardt says. "Gynecomastia is certainly one area where we have seen this." Pinkner says gynecomastia is almost always in the vague language of "reconstructive surgery is to restore function, and because there is no function of the male breast, surgery is cosmetic.
Reduction mammoplasty is another example of a procedure that often won't be covered by insurance companies, sources say. Insurance company reps will say, "I'm not telling you it's not appropriate or not medically indicated; I'm just telling you that based on our contract, this is not a covered procedure," Erhardt says. "It's becoming harder and harder for all of us in health care to provide appropriate health care to our patients when we have to deal with the insurance industry."
Consider these suggestions:
• Approach the insurance company armed with information.
As a first step, tell the insurance company exactly why the procedure is medically necessary, suggests Robert Aicher, Esq., general counsel for American Society for Aesthetic Plastic Surgery. The insurance company may require a second opinion and perhaps an examination by a physician selected by them, "but with perseverance, the process can be successful," Aicher says.
Consider sending a photograph that shows the condition of the patient, Pinkner suggests. In the case of gynecomastia surgery, a photograph can address the concern of the insurance company that a boy has breasts because he is obese. Also, the insurance company may request letters from pediatricians or other physicians that explains the patient's problems and how long the patient has had the condition.
• Have the patient or a family member become an advocate.
When a medically indicated procedure is rejected for payment, have the patients or their family members talk to their company's human resource representative, Erhardt advises.
"It's unfortunate, but it's one of those things where the squeaky wheel gets the grease," he says. Erhardt has seen insurance companies reverse their decision when this tactic is used.
• If turned down, consider publicizing the case through the media or through legal actions.
Erhardt says, "In the past, I've known insurance companies to back down when publicity comes to a case." He commends the father in this case. "So many times, it's like the patient, David, going against the insurance company, Goliath," Erhardt says.
This case is a triumphant one, Aicher says. "That father is a great example of the level of energy and perseverance often required to establish medical necessity and should be an inspiration to others in similar situations," he says.