Thursday, July 15, 1999
Boy's big breast outside insurance policy
BY TIM BONFIELD
The Cincinnati Enquirer
Doctors say a 17-year-old Tristate boy with a hormone problem needs surgery because he has grown a breast big enough to fit in a size 34B bra.
But the family's HMO — Anthem Blue Cross & Blue Shield's Community Choice plan — won't pay for the surgery because “cosmetic” procedures are not covered.
“I've made phone calls. I've written letters and sent in photos. But they've said, "No.' It's absurd,” said Dr. Paul Chirlin, a pediatrician with offices in Springdale and Mason.
The boy — whom The Enquirer is not naming at his family's request — has been diagnosed with gynecomastia, an abnormal enlargement of the male mammary gland that affects as many as 10 percent of all men.
The dispute comes amid debate in Washington and Columbus over patient bill of rights.
“It's fairly common among boys as they hit puberty,” Dr.
Chirlin said. “What's unusual is that (this boy) developed a B-cup sized breast.”
After receiving news Wednesday that coverage was denied, his mother told The Enquirer that the situation has been “horrible.” She described her son as an otherwise typical teen-age boy who likes to play basketball and wants to date girls. He tries to hide his condition by wearing baggy clothes.
“He's been ridiculed at school. He's embarrassed to get undressed in the gym. How can they say this is cosmetic? Boys don't have breasts,” she said.
The boy was first diagnosed in 1995. At the time, doctors advised the family to wait because enlarged breasts occurring in boys just entering puberty often fade away by themselves.
One breast did shrink. The other didn't. Several weeks ago, Dr. Chirlin recommended surgery, an assessment confirmed by Dr. Victor Garcia, a surgeon at Children's Hospital Medical Center.
The cost would be at least $1,800, possibly as high as $5,000, depending on the extent of hospital services, anesthesia fees and follow-up tests and exams. But Anthem won't pay.
“It isn't a question of whether the surgery is appropriate. It's a question of whether the procedure is covered under this policy,” said Dr. Neeraj Kanwal, lead medical director at Anthem.
Anthem covers “reconstructive” plastic surgery to restore normal function and appearance for serious birth defects, burns, disease or injury.
However, Anthem considers surgery for gynecomastia to be “cosmetic” plastic surgery. Anthem does not pay for cosmetic surgery unless there is documented evidence of a “functional impairment,” such as severe pain or lack of function that prevents carrying out normal activities.
Dr. Janice McConville, regional medical director at Anthem, said she has seen the boy's pictures and his medical records. The boy has not shown any signs of infection, bleeding, cancer or anything else that rises to a medical “need” for the surgery.
“Would I notice him at a swimming pool? Yes, I would notice him,” Dr. McConville said. “But this problem is purely one of appearance and psychological distress.”
The boy's mother was outraged by Anthem's response.
“I still don't understand. He's a boy! My son shouldn't be walking around disfigured,” she said. “I waited for four years because my doctors said I should. Now, if my doctor says this is the way it should be handled, how can an insurance company say no?”
To this mother, correcting an enlarged breast in a teen-age boy is vastly different from expecting an insurer to pay for liposuction or a nose job.
Untreated, she can imagine her son growing up to have trouble meeting women, trouble in social situations, and ultimately, serious depression.
“I think my boy is pretty strong. But what if he's not? What if this makes him consider suicide?” she asked. “If he develops lots of psychological problems, he could end up costing them a lot more.”
The family has the option to appeal to an Anthem corporate-level review board.
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