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

Question

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

Jerome Edelstein, MD · Answer

You should ask your insurance provider if your surgery would be covered. However, in general, tubular breasts are not a health hazard. Corrective surgery is aimed more to improve their aesthetic appearance, rather than improve function or address a health problem.

Jed H. Horowitz, MD, FACS · Answer

In considering your Plastic Surgeon to help correct your Tuberous Breast, choose someone with a great deal of breast surgery experience of all types. This surgery is multifaceted requiring a Board Certified Plastic Surgeon well trained in all types of cosmetic and reconstructive breast surgery. Dr. Horowitz has an aesthetic vision and detailed eye combined with the finesse and skill to work with you to achieve the improvements you desire. It is critical to analyze the shape and contours of both breasts and understand beautiful, natural aesthetics of the breast and body. A passion for detail and the ability to form a warm and caring bond with his patients is essential to help treat this deeply emotional medical condition and improve your sense of well being and self-esteem which can completely transformative.

Intended Results

The ultimate goal is to achieve improved breast shape and symmetry as best as is possible given the starting anatomy. Realistic goals and expectations are important, as in all surgery. It is common that more than one operation is required and the breast shape will change even during the first few months after surgery.

Healing

This will depend on the procedures used and can be found in the sections on Breast Augmentation, Breast Lift, and Breast Reduction.

Insurance

Although this is technically a reconstructive operation by definition, many insurance companies will unfortunately and unreasonably have specific exclusions in their guidelines.

Lewis Albert Andres, MD · Answer

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.  Some insurance plans have exclusion 
criteria for certain procedures.  Also, it is an obligation of the 
surgeon not to attempt to authorize purely cosmetic procedures through 
insurance.  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 of 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. 
Certainly, pay in advance prior to your surgical procedure and options 
such as financing are available if you qualify. Hope that this helps! 
 Best wishes!

David Shafer, MD, FACS · Answer

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.

Richard H. Tholen, MD, FACS · Answer

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!

Craig S. Rock, MD, FACS · Answer

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.

Ernesto Hayn, MD · Answer

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.

Moneer Jaibaji, MD · Answer

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

Darryl J. Blinski, MD · Answer

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.

David Greenspun, MD, MSc · Answer

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.

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