Does Insurance Cover Tubular Breasts Since It is Considered a 'Congenital Anomaly' ?

My insurance company is united healthcare. I live in NYC so if there are any doctors who are willing to work with me and my insurance company please email me at MyElectroFetish@aim.com

Doctor Answers (13)

Insurance coverage for plastic surgery procedures

+1

Insurance policies, even with the same company, can vary widely. It is always advisable to get in writing from the insurance company a predetermination as to whether the specific procedure you are considering is covered under your insurance policy. If they deny it, you have several options. One is to appeal and they should tell you what the appeal procedure is. Another is to proceed with the surgery on a cosmetic, self-pay basis and there are financing options available is that is an issue for you. Or you can not have the surgery. But be sure to get the determination before the surgery; they will deny your claim if you have the surgery without prior authorization. Your surgeon should be able to work with you to find out from the insurance company what your policy covers. Good luck.


Sacramento Plastic Surgeon
3.5 out of 5 stars 8 reviews

Insurance company and tubular breasts

+1

I have had several patients with tubular breast deformities and several refusals by insurance companies.  You have to look closely at your policy.   They base their refusal to cover this congenital deformity by indicating that a physical DISABILITY must accompany the congenital deformity in order for coverage to be approved.  Having said that I am sure your surgeon will gladly work with you and assist you to obtain approval from your insurance company.

Ernesto Hayn, MD
West Palm Beach Plastic Surgeon

Insurance coverage for tuberous breasts

+1

Usually insurance will only cover breast surgery if there is associated breast cancer or hypermastia.  I have never had a tuberous breast deformity covered.  Donald R. Nunn MD Plastic Surgeon.

Donald Nunn, MD
Atlanta Plastic Surgeon
5.0 out of 5 stars 5 reviews

You might also like...

Anomaly is not a deformity

+1

Although there are different grades of tubular breast, the correction procedure is not covered by insurance companies. But, to satisfy your curiosity, try contacting your insurance company and see what they say. Personally, I have not seen a case of tubular breast covered by any insurance company. It is a cosmetic procedure and your local plastic surgeon will advise you on the type of surgery and cost. Good luck

Moneer Jaibaji, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 3 reviews

Insurance coverage for tubular breasts

+1

In most cases, insurance companies consider tubular breast surgery a cosmetic procedure.  However, it never hurts to contact your insurance company to check on your individual policy.  As plastic surgeons, we have no control over what the insurance company will cover.  After a consultation, we can write a letter and send photos and maybe a sympathetic insurance company would agree to cover it, but don't hold your breath - insurance companies generally try to find any excuse to not cover a procedure.  If money is an issue, most offices offer some type of financing programs such as Care Credit where you can pay for the procedure over time.

 

Good Luck.

David Shafer, MD
New York Plastic Surgeon
5.0 out of 5 stars 54 reviews

Surgery for tubular breasts is usually not considered reconstructive.

+1

The same thing applies to protruding ears, large noses, and even large breasts, though insurance coverage is sometimes obtainable for breasts large enough to exceed certain height/weight guidelines.

But, tuberous breasts are generally considered "cosmetic" in nature by most insurance companies. You should see one or more ABPS-certified plastic surgeons in New York who can tell you honestly what your chances are of obtaining coverage. Truthfully, I would expect them to be low. I practice in Minnesota, the home of HMOs and health-care insurers, and have been a reviewer for Blue Cross/Blue Shield and Medicare for years--this would not be a "covered" expense, even with appeals.

So, be prepared to pay, but that means you get to choose the expert plastic surgeon who you want to do your surgery. Interview carefully, and choose wisely, so your result is good and you are happy. . . otherwise, you may end up having additional reconstructive work (that may or may not be covered as well) to correct poor initial surgery! For examples see cases 1 and 3 via the link below. Best wishes!

Richard H. Tholen, MD, FACS
Minneapolis Plastic Surgeon
5.0 out of 5 stars 109 reviews

Does Insurance Cover Tubular Breasts Since It is Considered a 'Congenital Anomaly' ?

+1

I'm not sure if you are asking a "why" question or looking for boarded New York PS's to write a predetermination letter to UnitedHealth? If your deformity is severe tuberous and amastia/hypomastia with asymmetry than you may be approved. But in general tuberous symmetrical deformities are  rarely approved, especially with UnitedHealth Care. If you had posted a photo we could be more specific upon your possible chances for approval. 

In the predetermination letter the PS MUST enclose a photo of your breasts. So the medical advisory board for United care review and make their determination. Best of luck. 

Darryl J. Blinski, MD
Miami Plastic Surgeon
4.5 out of 5 stars 61 reviews

Insurance coverage for tubular breasts

+1

Although tubular breasts may be considered a congenital anomaly, insurance companies generally tend to limit coverage to issues that create a functional problem (reconstructions after breast cancer are an exception, and coverage is required by federal law). You should be able to find a plastic surgeon on your insurance plan who is willing to see you and then submit a pre-determination letter to your insurance company.  If you are denied, you can appeal the decision, and sometimes your employer can help (though the chances of having the decision reversed are small).

Good luck.

My response to your question/post does not represent formal medical advice or constitute a doctor patient relationship. You need to consult with i.e. personally see a board-certified plastic surgeon in order to receive a formal evaluation and develop a doctor patient relationship.

Craig S. Rock, MD
Houston Plastic Surgeon
5.0 out of 5 stars 15 reviews

A matter of degree

+1

Like any congenital deformity there are matters of degree.  Many breasts are labeled tubular that are mild enough to constitute cosmetic problems.  Most insurance companies have lower limits of tissue resection to consider a breast reduction "functional" and eligible for coverage.  Tubular breasts in their more severe forms are truly a deformity, but there is no clear line (like a weight) that insurance companies can use to objectively determine the need for coverage.  So they deny any coverage.  You can try to get your procedure covered (be sure to send them photos with your request for authorizartion), but I would expect a denial.  Most plastic surgeons will work with you on costs.  Ask about financing and payment plans, but expect to pay.  Good Luck. 

Lori H. Saltz, MD
San Diego Plastic Surgeon
4.5 out of 5 stars 11 reviews

Insurance Coverage for Tubular Breast Surgery

+1

I agree with the other surgeons- obtaining coverage can be difficult, but it is not necessarily impossible. Whether or not you are eligible to have insurance coverage for surgery will depend on how severely you are affected and on your insurance plan's "specific plan benefit". The specific plan benefit is essentially the contact you have with your insurer that specifies whether of not such surgery might be covered or is automatically excluded from coverage. If it might be covered, you will need to have your doctor send a letter and clinical photographs for medical review by an insurance company doctor. In some cases, we have been successful in obtaining coverage for surgery when the situation was clearly reconstructive.

In the event that surgery is not covered,  many plastic surgeons will work with you to try to find a financial arrangement that is comfortable. 

Best of luck.

David Greenspun, MD, MSc
New York Plastic Surgeon

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.