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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 (5)

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

+1

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.

Nashville Plastic Surgeon
5.0 out of 5 stars 21 reviews

Does insurance cover congenital problems with the breast?

+1

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.

Austin Plastic Surgeon
5.0 out of 5 stars 48 reviews

Probably not

+1

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.

 

Atlanta Plastic Surgeon
5.0 out of 5 stars 7 reviews

Insurance coverage for Turner's syndrome

+1
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.
New York Plastic Surgeon
5.0 out of 5 stars 8 reviews

Insurance Coverage for Congenital Birth Defect Reconstruction?

+1

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.

Web reference: http://www.poustiplasticsurgery.com/Procedures/Procedure_breastAugmentation.htm

San Diego Plastic Surgeon
5.0 out of 5 stars 627 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.