Possiblibity of Prior Auth for Implants for a 20yr.old Girl with Estrogen Deficit Anolomy

My niece has a documented estrogen deficit and is on estrogen therapy in order to menstruate since age 16. She has no breast development, and would like implants to have a normal body. Is there any chance a prior authorization could be done to have insurance coverage for the procedure? (she is mearly looking to have some normalcy--A cups would make her happy) Does insurance always consider this an cosmetic elective procedure?

Doctor Answers 3

Insurance Coverage For Implants For Congenital Breast Defects

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The chances of insurance providing coverage for breast 'reconstruction' for this condition is about as close to zero as I can imagine. Even in cases of profound medical reasoning, many breast procedures are denied today due to lack of a functional benefit. However, the only way to know for sure is to consult with a plastic surgeon and have a predetermination letter submitted. This letter will outline the medical diagnosis, proposed treatment plan and will have photographs to demonstrate the medical problem. The insurance company will provide a written response of their decision.That is the only way to know for sure. Without a predetermination, anyone's thoughts are just opinions and not facts.

Insurance coverage for breast implants

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Insurance coverage is quite variable for breast implants, even with a well documented medical condition. If your endocrinologist feels that with replacement therapy there will be no further breast development a letter of support and an appeal to your insurance provider in the form of a predetermination of benefits will sort things out.

Best of luck,


Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 44 reviews

Insurance coverage for breast defects

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Hi, unfortunately, insurance companies will almost always consider this a cosmetic case, even in the face of an obvious underlying medical cause.  You can call your insurance company yourself and given them the code 19325 (breast augmentation) if they ask for it.  Best wishes, /nsn.

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