Access to Surgical Treatment of Adolescent Gynecomastia

Background Insurance coverage for surgical correction of adolescent gynecomastia remains highly variable. This study defines the rate of preauthorization denials and identifies patient and payer characteristics associated with denials. Secondary objectives include quantifying treatment rates among those denied coverage and characterizing reasons for denials. Methods A retrospective review was performed of all pediatric patients evaluated for gynecomastia at the Children's Hospital of Philadelphia between January 2011 and June 2024. Demographic, clinical, insurance, and preauthorization data were collected. Multivariable logistic regression was used to identify predictive factors for denial and out-of-pocket payment. Results Among 360 patients, the mean age at the first visit was 16.3 years (SD 2.0), with a mean gynecomastia duration of 4.2 years (SD 2.7). Most had Grade 2 (n = 146, 40.8%) or Grade 3 (n = 104, 29.1%) gynecomastia. Of the 282 patients (78.3%) who pursued treatment, 66 (23.4%) received preauthorization from their primary insurance, 11 (3.9%) were approved through secondary coverage, and 205 (72.7%) were denied or offered out-of-pocket pricing. Denials often resulted from contract exclusions due to cosmetic classification (n = 99, 45.8%); however, 31 denials (14.4%) cited insufficient documentation. On multivariable analysis, approval was associated with Public Insurer A coverage (OR = 100.5, P < 0.001). Bilateral disease was associated with decreased odds of approval (OR = 0.1, P < 0.01) relative to unilateral disease. Of the 207 patients (57.5%) who underwent surgery (n = 137, 66.2%) paid out-of-pocket, with 85.6% of these opting for lower-cost adult facilities. Black patients (OR = 0.4, P = 0.01) were less likely to self-pay relative to White patients. Conclusions Insurance coverage for adolescent gynecomastia is primarily restricted by policy-level exclusions rather than clinical factors, resulting in high denial rates and frequent reliance on self-pay options. These trends, along with observed racial differences in self-payment, underscore the need for standardized, evidence-based coverage criteria to address barriers to surgical access.