Would Insurance Cover the Cost of Plastic Surgery for a Congenital Birth Defect?

I have turners syndrome. Do to the congenital defect I have almost no breast tissue and widely spaced nipples. Would insurance ever cover the cost of having this corrected?

Doctor Answers (6)

Would Insurance Cover the Cost of Plastic Surgery for a Congenital Birth Defect?

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Hello!  Thank you for your question!   Surgical procedures for aesthetic purposes, to improve appearance, are not covered by insurance. Typically, these as well as complications resulting from such procedures are the responsibility of the patient.  Procedures that are meant to correct functional issues and those which cause health-related issues should be covered by your insurance as a medical necessity, with proper examination and documentation. 

Congenital issues are a difficult issue, but usually found to be cosmetic in nature. With Turner Syndrome and the issues that you describe, there is no functional impairment of the appearance of your breasts.  Although I do agree with you regarding the complaints and the congenital defects, in my practice it has been difficult to get authorization and termed as aesthetic in nature by most insurance companies. 

Discuss your issues and complaints with a board-certified plastic surgeon to discuss these as well as to examine and assist you in deciding which procedure(s) will be the best for you.  A discussion if the advantages and disadvantages will take place along with the risks and benefits.  Insurance companies will vary on coverage and is always reasonable to discuss your issues with your surgeon and primary care. It would behoove you to get as much information as possible and even call your insurance yourself.  Hope that this helps!  Best wishes!


Scottsdale Plastic Surgeon
5.0 out of 5 stars 12 reviews

Sometimes insurance covers the cost of plastic surgery for congenital problems with breast development.

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Thank you for your question.  While no one can give you a specific answer in this venue, here is some general information that my help.

Insurance companies typically cover conditions that cause a functional problem and are medically necessary.

If a condition causes problems with self-confidence and self-esteem and the surgery is designed to improve appearance, then this is usually considered cosmetic in nature and not covered by insurance.

Each insurance company is different and there are many different insurance plans within each company.

To know the answer for you specifically, see your board-certified plastic surgeon and ask them to submit a claim to your insurance company ahead of time for predetermination and precertification.

I hope this helps.

J. Jason Wendel, MD, FACS
Nashville Plastic Surgeon
5.0 out of 5 stars 40 reviews

Does insurance cover congenital problems with the breast?

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Turners syndrome can lead to hypoplasia of breast tissue and a wide-spaced appearance to the breast.  Although this is congenital, in my experience it is difficult to get insurance companies to pay for correction of these problems.  These companies are rarely interested in how a patient "looks" or "feels".  That being said, it could be of value to contact your insurance company, directly and ask them about their coverage for this problem.  I wish you well.

Dustin L. Reid, MD
Austin Plastic Surgeon
5.0 out of 5 stars 58 reviews

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Probably not

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Insurance companies are very strict   about coverage for surgery to improve your breasts unless you have breast cancer.  You should see a board certified plastic surgeon to be evaluated.  He/she should apply for prior approval from your insurance company so you know where you stand. Turner's Syndrome has other findings than breasts.  I recommend you see an endocrinologist before you do any kind of surgery.

 

E. Anthony Musarra II, MD
Atlanta Plastic Surgeon
4.0 out of 5 stars 9 reviews

Insurance coverage for Turner's syndrome

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It has been one of my great frustrations that insurance companies in NY have done everything possible to avoid paying for congenital and developmental defects such as Turners and Pollan's syndromes. They pay for reconstruction after mastectomy only because federal law mandates that they do so. I am not optimistic that you will be able to have the procedure covered by insurance but would encourage you to review your plan specifications in detail. The insurers use the standard of "functional medical necessity" to avoid paying for breast surgery on the basis that correction of the defect will not improve function.

Robert L. Kraft, MD
New York Plastic Surgeon
5.0 out of 5 stars 13 reviews

Insurance Coverage for Congenital Birth Defect Reconstruction?

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Thank you for the question.

Yes, it is possible that health insurance will cover breast reconstruction to repair congenital birth defects.  The best way to know for sure is to contact your specific insurance company and ask about   your policy and procedures that may be covered.

I would also suggest starting with the American Society of Plastic Surgery and/or the Aesthetic Society of Plastic Surgery to obtain a list of well experienced board-certified plastic surgeons.


Then,  visit a few surgeons whose practices  concentrate on breast surgery and ask  to see lots of examples of their work and preferably speak/see patients who have had similar procedures done.



Your plastic surgeon will be able to assist you in your interaction with the health insurance company.

Best wishes.

Tom J. Pousti, MD, FACS
San Diego Plastic Surgeon
5.0 out of 5 stars 792 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.