Is Gynecomastia Surgery Covered by Health Insurance?

Gynecomastia is the clinical name for a condition affecting around 36% of Australian men: enlargement of glandular breast tissue in males, also known as ‘man boobs’. In most cases, it is harmless, without connection to any diseases or disorders, and the only negative side effects are the change in your appearance.

Benign gynecomastia occurs normally in infants, during puberty, and after middle age. In adult males, it can occur as a side effect of body building steroids and prescribed medications. Steroids can cause gynecomastia onset to happen quickly and lead to the most severe cases, and unlike fat deposits, glandular tissue, once enlarged, can’t be decreased through exercise or weight loss.

If you’ve developed gynecomastia, you can choose to cover it up with compression shirts, treat it slowly with a herbal supplement like Gynexin or with medically administered hormone therapy, or you can get rid of the fat and glandular tissue overnight through surgery.

Is surgery the best way to treat gynecomastia?

Surgery is definitely the most permanent option, and the quickest. Even with the four to six weeks of recovery time, you will still be able to regain your old lifestyle sooner than if you start hormone therapy. Compression vests will give you great temporary results for minor cases, and medical therapies may work over time, but getting rid of the tissue altogether is the surest way to achieve perfect results and ensure that the enlargement problem doesn’t come back.

If you’re considering surgery, talk to your GP and get a referral to a gynecomastia specialist. Surgery has risks, as does hormone therapy, and your specialist will ask you about your medical history and talk you through your options, prognosis and the surgery appointment process. They’ll let you know how long you can expect to need for recovery based on your unique physiology and the extensiveness of the surgery they are planning. They may suggest a different course of action other than surgery that is more suitable for you.

Is Gynecomastia surgery covered by insurance?

This depends on your insurance cover: who your provider is, and what level of cover you’ve paid for. Your coverage may also be affected by whether or not you had gynecomastia before you signed up to your current plan. In many cases, a standard out-of-the-box insurance plan won’t cover pre-existing conditions.

Liposuction and the surgical procedure

As we’ve discussed elsewhere on this site, true gynecomastia is not just extra fat which has been deposited: it’s a change in the size and shape of the glands in your breast. Liposuction removes fat but cannot remove glandular (also known as ductile) tissue. What’s more, if the problem is ongoing growth of breast glands due to a hormonal imbalance, leaving the glands in place will allow them to continue to grow. Liposuction is, however, often used in conjunction with surgery on the glands, as it removes fat from between the enlarged gland formations and helps return the chest to a smooth, tight, ‘masculine’ appearance.

During gynecomastia surgery, including the liposuction element, you’ll be under a general anaesthetic for around two hours. Before you can go in for surgery at all, you’ll have to be free of any anabolic steroids for at least six weeks as they can cause serious complications with anaesthetic and for the way your body responds to the surgical process.

After surgery, you’ll need to stay in bed completely for two or three days. After that, you can slowly resume light day to day activities, and low impact exercise after a further two weeks or so. You may be restricted from driving, and you can expect four to six weeks after surgery before you can really resume your pre-surgery lifestyle. Cardio and weight-lifting exercise is important to keep your body fit and healthy, and to sculpt your post-surgery chest into its optimal shape, but you’ll have to wait before you can really start your exercise regime in earnest.

A personal approach

The manner and extent of the surgery you need will be decided on by an experienced gynecomastia surgeon. It depends on the ‘grade’ and ‘type’ of your gynecomastia, as well as your general body shape, curves, skin condition and BMI. Provided you can afford it, surgery will definitely achieve the best possible results, and is guaranteed to solve your problem.

Getting the right insurance

So, how can you get insurance that does cover gynecomastia surgery? First, go through the product disclosure statement (PDS) for your existing cover, looking for a mention of gynecomastia by name. If you cannot find gynecomastia specifically, look for the section on elective surgery. If you cannot find your PDS, run a search in the insurance provider’s website. Hopefully you’ll get at least one result which tells you what category this surgery is classified under, and then you can check whether or not your existing plan covers that category of treatment.

If your insurance plan does potentially cover surgery for gynecomastia, you may still need to jump through a few hoops. For example, you might have to have a written letter from your specialist recommending that surgery is the best or the only option for your case. As a rule, the Australian Society of Plastic Surgeons recommends that any gynecomastia symptoms diagnosed as grade 2 or higher should be covered automatically by any insurance plan.

If you have comprehensive insurance, there’s a good chance that it will cover all of your initial appointments for assessment and discussing treatment options. If you cannot get a recommendation from a qualified specialist, you may have to tackle the issue from an elective /plastic surgery angle. It’s not uncommon for women to request breast reduction surgery in Australia without needing the surgery for immediate or serious health reasons, and the highest (most expensive) levels of comprehensive health cover in Australia occasionally extend to private elective surgery.

Coming from this angle, you’ll still need to speak to a professional and get a tailored surgery plan and a quote to provide for your insurer before you can be certain that they’ll cover some or all of your treatment.

As a rule, to be automatically eligible for coverage of your surgery, you’ll need to fulfil these key criteria:

• You must exhibit a diagnosable, well-defined case of gynecomastia, generally Grade 2 or worse, which requires treatment.
• You must prove that the physical abnormality has negatively impacted your functioning.
• This deficit in functioning has to be recurring or persistent.

When will coverage be provided?

In some cases, gynecomastia is not benign and simply a matter of an undesirable change to your physical appearance. If gynecmastia is causes significant physical discomfort or pain, discharge, or, in rare cases, even tumours, you will definitely be covered for surgery, as it will be deemed necessary. If this is the case, your GP and specialist will order tests to determine the causes and possible complications, to rule out cancer, hyperthyroidism or other underlying health problems, and to determine the safest and most effective treatment plan for you. Before covering the costs, your insurance company needs proof of your health condition and a thorough breakdown of the costs associated with treating it. You’ll need to prove that the treatments you seek are recommended by, and administered by, approved health professionals accredited by the relevant authority (e.g. the Australian Society of Plastic Surgeons).

When won’t coverage be provided?

Even gynecomastia that is defined as mild or ‘grade 1’ can be soul-crushing and seriously effect a man’s self esteem and comfort in his own body. Hundreds of thousands worldwide have to put up with the lack of confidence and even depression that can result. However, from the perspective of your insurance company, you’re going to have to exhibit a certain severity of symptoms or dangerous complications before they will cover the expense of surgery straight away.

The majority of the time, an improvement to your self esteem and psychological wellbeing will not be enough to get your insurance provider to cover surgery for you.

What if I’m denied?

You may ask to undergo further testing that could produce sufficient evidence that surgery is necessary, or you may have to prove (through the opinions of specialists) that alternative therapies like hormones are not possible in your case. If you are still knocked back, you may need to submit to alternative treatments, knowing that if they are in fact unsuccessful and your condition remains the same or worsens, you might qualify for surgery later on.

Importantly, you should keep visiting the same GP or specialist, so that they can build up a good record of how gynecomastia has impacted your life and for how long. In some cases, you just need to show that it’s been unresolved for long enough to warrant serious treatment.

Why isn’t coverage provided?

Insurance companies essentially exist to make money, and to do that they need to restrict the treatments they’re willing to pay for. By including surgery for mild cases of gynecomastia in the same category as elective cosmetic surgery, they are able to keep strong boundaries up between what they will and won’t cover, and thus keep their costs down and their profits high.

Other payment options

If you can’t get your provider to cover you, who may still be able to get finance. A personal loan might apply, and some plastic surgery firms even offer financing in house. If you can meet your repayments in your budget, taking this financial risk might be worth it for the quality of life you’ll gain now instead of waiting to save the money from scratch.

Pros & cons of gynecomastia surgery

If it’s possible for you, the pros definitely seem to outweigh the cons:

• It is the single treatment that guarantees a permanent reversal for gynecomastia
• Even taking recovery into consideration, you get the quickest permanent results
• You have a much better idea of what results you can expect, and the results are almost certain to be better than the results achievable with non-invasive medical therapies
• While you’re under the knife, your surgeon can dramatically improve the shape and contours of your chest, so you won’t end up with persistently loose skin (as you would with weight loss and hormonal therapies)

There is essentially just the one con to gynecomsatia surgery: the cost. Surgery has complications but they are actually a little easier to anticipate and treat than the huge and subtle range of complications that can occur as a result of hormone therapies. Complications from hormone therapy can take months to present and continue to have domino effects in your system for a long time after you cease taking the medication. If you can afford the surgery and the holiday you’ll need to take afterwards, there’s no reason not to go straight for the quickest and most effective treatment option available to you.