CASE SUMMARY - MEDICAID/HUSKY

Larry

Larry is a 13-year-old boy diagnosed with neurofibromatosis (NF) and gynecomastia and insured by Connecticut’s Husky A (“Husky”) plan, also known as Medicaid, which is administered through the Department of Social Services (DSS).  The Managed Care Organization (MCO) administering his health care plan is Blue Care Family Plan (BCFP).  For the NF and gynecomastia, Larry has been under the ongoing care of doctors at the Connecticut Children’s Medical Center (CCMC).  Over four years ago, at age seven (7), Larry began to grow breasts despite his normal weight, hormonal levels and lack of endocrine disorder.  The condition has not abated since that time. 

Larry’s doctors are recommending that he undergo a mastectomy, which they consider to be a medically necessary surgery and the only solution to Lorenzo’s gynecomastia (i.e., there is not considered to be any effective pharmacologic treatment in his case). His doctors do not believe that after four years this condition will resolve itself and Lorenzo has become very shy and self-conscious because of the condition.  Even if all of the other boys are taking off their shirts to go swimming, Lorenzo refuses to do so.  He has requested to be held back in school and is afraid of changing in a locker room with other boys.  His doctors and the boy’s mother are now worried about the psychological effects that having breasts will have on Lorenzo as he moves into his adolescent years. 

A request was made to BCFP that it cover the costs of the mastectomy.  However, BCFP refused to do so, stating that a mastectomy for gynecomastia is not medically necessary or appropriate, and therefore not covered by Medicaid.  Contrary to his treating physicians’ beliefs, BCFP also claims that the condition will likely resolve itself once Lorenzo finishes puberty.  Lorenzo and his mother have appealed the decision by BCFP to deny Medicaid coverage for the mastectomy.

The MLPP attorney did an immediate intake of the family and assessed their eligibility.  The MLPP attorney determined that since Medicaid is a federally and state funded program that is mandated by federal law, relevant statute dictates that Medicaid pay for all medically necessary treatment of conditions, necessary to “correct or ameliorate defects and physical and mental illnesses and conditions”.  The case was brought before the Connecticut Superior court, where the judge vacated the original denial and ordered a new hearing.