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American Medicine: Medicaid and Child Abuse
September 10, 2007
This is a picture of a teenage boy with Gynecomastia. Obviously, gynecomastia is an abnormal enlargement of the male breasts. It happens in some teenagers - and is worse in those with obesity. Just how cruel do you think these kids are treated in high school and middle school?
I have a young boy who is 13 and has marked gynecomastia which has been present for over two years. I requested a plastic surgery consult (which is usually my practice) in this situation and the surgeon agreed that he was a good candidate for a surgical fix and submitted the request to our Medicaid managed care provider. I have never had a denial of this when the situation clearly seemed to warrant this. In fact, this child had been approved to have the procedure done a year prior to now but had not gotten it done out of fears and misconceptions about the procedure.
He is now being denied by the Medicaid managed care company. The grounds? No documentation of degree of enlargement and child not old enough.
Disgraceful.
I seriously considered not putting the above picture up as it is disturbing to look at, but really isn’t that the point? Would you want to be this child?
I had to write a letter for him today stating that he can change for PE in private.
This is abuse. The state prosecutes child abuse. The same organization that runs Medicaid also investigates child abuse. So how can the state sanction this? I have expressed my outrage to the “proper authorities” but got the usual blah, blah, blah.
Saving money at the expense of a child’s psychologic stability is wrong, and makes me mad as hell.
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Posted in American Medicine, Being a Doctor, Pediatrics, Rants
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September 23rd, 2007 at 6:27 pm
Dr. Rob, you have documentation. They are just pulling the stall tactic. The plastic surgeon will have his/her notes from the boy’s visit. You have your notes (especially if you have seen him over the past 2-3 yrs). Request a medical review or have the surgeon’s office make the call (that is what I would do–make the call personally). Yes, it is frustrating. This is when I rant for a day, cool off, then write another letter or make the phone call. Since the ICD-9 code is the same for female and male breast hypertrophy, make sure they realize the patient is male.
http://rlbatesmd.blogspot.com/2007/08/gynecomastia.html
September 23rd, 2007 at 6:28 pm
Dr. Rob, your advocacy is showing. Likewise with your first commenter. Bates says he waits till he is calm to make his follow-up phone call, but I think righteous indignation would be just fine in this case. No need to protect the child abuse system from wrath. Go ahead. Make an angry call!
I wonder if any one else has ever pointed out that their dual role–that of giving permission for procedures and pursuing child abusers represents a conflict of interest. Legally untenable.
You (and I and all of us who care about kids) are dealing with not one, but two systems that are so hidebound with rules and ungainly that the system cannot “feel” the pain of being made fun of that your 13-yr-old patient feels. When you phone them, if you pin them down, they will probably say that they cannot let feelings enter into the discussion.
But protecting children emotionally is part of protecting them. Period. It isn’t just their nutrition, their shelter, their health. It is their emotional well-being–in this, you are treating your patient wholistically. Bully for you. Spell out the word for the managed care company administering Medicaid. Ask them to look it up. Make it part of their guidelines. Tell them somebody up there–big brother?–is watching.
Chris and Vic
September 23rd, 2007 at 6:29 pm
P.S.
Oh, and the 2nd system that is too big is the educational system which cannot protect children from bullying or being made fun of by their classmates.
September 23rd, 2007 at 6:30 pm
Have you filed an appeal? I used to be the appeals nurse for these type of cases at an insurance company and I can’t recall ever actually having one fully denied like this. With the reasons they gave you, it sounds like it would be overturned on appeal, especially if a plastic surgeon reviews it.
September 23rd, 2007 at 6:34 pm
My own son inherited this trait from his father. Most of the men on his father’s side of the family have it. But the scariest part of this trait—it makes them more likely to have a rare form of breast cancer. My son’s father died from this cancer as well as several of the male members in his family. My son never goes without a shirt. He hated PE when he was in school and would skip on a regular basis. He is now 24 years old and would love to have something done, but it is considered cosmetic by his insurance company. Even with the extensive family history.
I hope you are able to force the issue in this case.
September 23rd, 2007 at 6:35 pm
I operated on lots of boys with gynecomastia (after trying to wait it out). Getting certification was often a frustrating problem. The ones who really need it, really need it.
September 23rd, 2007 at 6:36 pm
I have actually appealed and spoke with the physician in charge. They simply stated the rules and said he was too young. I had forgotten some about the case until today when they called and asked for the note. The fact is, the insurance companies depend on the fact that we are too busy with other stuff to take the time and energy to do so. I wrote my enraged letter and pointed all the facts about this case. It was flat out denied.
Regarding the conflict of interest, the government gives money to the MCO to run their insurance program. That same government arm runs DFACS. I don’t think there is a conflict here. Just irony.
September 23rd, 2007 at 6:37 pm
This seems to be what happens when a real patient turns into a case number and a policy number and a number-crunching policy wonk in charge of dispersing the bucks.
Just have the 13 year old guy go visit whoever denied his claim. Look into his eyes, look at his man-boobs… and then?
anecdotally, I have heard Gynecomastia is on the rise… why? Growth hormones in milk and meats? Something leaching out of plastics?
September 23rd, 2007 at 6:38 pm
World Health Organization (WHO) states that “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”
WHO. Constitution of the World Health Organization , Geneva, 1946. Accessed October 30, 2006.
http://w3.whosea.org/aboutsearo/pdf/const.pdf
this is eye opening for me as a student down under. i have yet to watch “sicko”, which apparently seeks to expose parts of the American healthcare system.
P.S. care to inject any objectivity into a budding doctor’s mind, anyone? your time will be much appreciated
September 23rd, 2007 at 6:38 pm
i know, quoting a 1946 definition is way out of place gee! if i did that for a research paper or project, i’ll be hung!
idealism aside now.
September 23rd, 2007 at 6:39 pm
I’m actually writing a post about extra nipples today. I wasn’t able to calm the mother down until I finally realized her concern and told her that the child would not have three breasts.
September 23rd, 2007 at 6:40 pm
Out of curiosity: If the subject of the image were to lose weight, say, down to a body fat percentage of 12% to 15% — how would that affect his gynaecomastia?
Or, asking this the other way around, would it be possible to save the taxpayer a few grand by _not_ spending money on food or videogames and substituting exercise instead?
Thanks,
Felix.
September 23rd, 2007 at 6:41 pm
Good thought, Felix, but sadly this does not improve with weight loss. It is glandular tissue, not fat. Given that it has been there for 2 years, it is even less likely to go away. I would not have referred if it was simply adipose tissue.