Access to Surgical Treatment of Adolescent Gynecomastia: Characterizing Insurance Barriers and Preauthorization...

Area of Science:

• Plastic Surgery
• Health Policy
• Pediatric Healthcare

Background:

• Insurance coverage for adolescent gynecomastia surgical correction is inconsistent.
• Preauthorization denials and their associated patient/payer characteristics are not well-defined.
• Understanding treatment rates post-denial and reasons for denial is crucial.

Purpose of the Study:

• To determine the rate of preauthorization denials for adolescent gynecomastia surgery.
• To identify patient and insurance characteristics linked to denial.
• To analyze treatment outcomes and denial justifications.

Main Methods:

• Retrospective review of pediatric patients with gynecomastia (January 2011-June 2024).
• Data collection included demographics, clinical details, insurance information, and preauthorization status.
• Multivariable logistic regression analyzed factors predicting denial and out-of-pocket payments.

Main Results:

• High denial rate: 72.7% of patients seeking treatment were denied or offered out-of-pocket pricing.
• Common denial reason: Contract exclusions for cosmetic classification (45.8%).
• Approval associated with Public Insurer A (OR=100.5); bilateral disease decreased odds (OR=0.1). Black patients less likely to self-pay (OR=0.4).

Conclusions:

• Adolescent gynecomastia coverage is mainly limited by policy exclusions, not clinical factors.
• High denial rates necessitate self-pay options, with many using adult facilities.
• Need for standardized, evidence-based criteria to improve surgical access and address racial disparities.