Change in health insurance coding that impacts breast reconstruction surgery; what it means for patients

Vanessa Vance said she is thinking about her family as she deals with her cancer risks. (Courtesy of Vanessa Vance)

AUSTIN (KXAN) – Vanessa Vance watched her mother and then her aunt battle cancer. She often wondered about her own possibilities, especially after having her child.

“My family has a long history of breast cancer. And so when I think about my future as a person, I’ve always said to myself, I’m going to be a person who gets breast cancer,” she said.

She discovered through genetic testing that she was at high risk for ovarian and breast cancer.

“I was able to have my fallopian tubes taken out,” he said. “So with a 40 to 60 percent chance of having a risk of breast cancer, you have a couple of different paths that you can choose from, but I think really being a mother of a child sort of affects the greater frankness for me. ”

Vance looked into his options and consulted with doctors and surgeons. Now he is in the process of getting a mastectomy and DIEP flap reconstruction surgery. It allows patients to use their natural tissue from their lower abdomen to create new breasts instead of using implants.

Encoding change

Vance has insurance but explained that he recently discovered that the surgery is only 70 to 90 percent covered after a recent insurance code change.

“I had my plans. I had my team. My surgeons have guided me on what is the best surgery for me. But now I’m like, ‘well, how does he get paid?’” she said.

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Her concerns are shared by women across the state and country.

Dr. Elisabeth Potter specializes in DIEP flap surgeries and has been listening to women affected by changes in insurance coverage. (Courtesy of Dr. Elisabeth Potter)

Dr. Elisabeth Potter, a breast reconstruction surgeon specializing in surgery, said the change in coding of DIEP flap groups with other less advanced flap reconstruction surgeries.

“There have been some coding changes that have equated all types of natural tissue reconstruction equally, and they really aren’t. Here, this is the essence of the problem. The surgeries we performed initially removed a woman’s muscle, the surgeries we perform now save a woman’s muscle. So, they’re very different from a patient’s point of view. And they are repaid differently. But one insurance company demanded a change so they could pay the same rate for all types of rebuilds,” Potter explained.

She added that the breast reconstruction was covered by insurance under the Women’s Health and Cancer Rights Act of 1998 which includes natural tissue and implants.

The Centers for Medicare and Medicaid Services, the government agency that oversees certain billing codes, said the change came after the American Medical Association and American Society of Plastic Surgeons revised an existing code to include DIEP. and other similar advanced flap procedures.

An agency spokesperson said CMS has not stopped medical coverage for DIEP flap surgery.

“One code, S2068, has been dropped as part of an update to the medical procedure coding system. The lifting of this code, which – again – does not change whether intervention is covered, is not effective until 31 December 2024, to ensure suppliers and payers have plenty of time to adjust their systems,” he added. the spokesman.

CMS said the change reduces the number of codes.

“This change does not mandate coverage of services by insurance companies. Insurers and providers can address the changes,” the spokesman added. “CMS is not a party to these negotiations.”

CMS said patients should talk to their insurance companies to understand if DIEP or other services are available in their provider network.

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But the AMA explained to KXAN that insurance companies are responsible for the payment policies they need for specific medical services.

“Commercial health insurers are under no obligation to follow the change in Medicare coding policy,” the association added.

The group of plastic surgeons said they did not request a change and were started by a private insurer.

“As you know, over the last year, several commercial health insurance companies have introduced categorical changes to their microsurgical breast reconstruction coverage policies. We are writing to assure you that these changes are triggering worrying reductions in access to this type of care”, reads a letter written by the ASPS president to CMS.

A spokesperson further explained that ASPS is dedicated to educating payers about patient reported value, clinical benefits, cost effectiveness and the importance of expanding access to these procedures.

“The goal is to ensure plastic surgeons can maintain and increase access to these procedures for every woman battling breast cancer,” the spokesperson said.

$50,000 out of pocket

Blue Cross and Blue Shield of Texas said in a statement that they will continue to reimburse S2068 procedures until further notice from CMS.

“Coverage determinations vary by benefit plan design and may be subject to medical necessity requirements. Coverage decisions are based on robust clinical research with our medical team working with physicians and researchers to constantly review the effectiveness of various medical treatments to produce high-quality, safe results. In doing so, we are good stewards of our members’ healthcare dollars by providing access to a broad choice of providers,” the statement said.

There have been no responses from other insurance companies.

While the coding change isn’t expected until next year, Dr Potter said some private health insurers have already made changes to coverage.

“You know, immediately, patients are going to find that their surgeons are having a hard time getting reimbursed for the surgery. I’ve already seen women all over the country being asked to pay cash out of pocket for surgeries. And that’s basically because insurance companies have drastically reduced the amount they are willing to pay for these surgeries. So, we’re seeing women being asked to pay for their breast cancer reconstruction surgery when it should be covered,” Potter explained.

In Texas, he said patients were being asked to pay $35,000 to $50,000 for the surgery out of pocket.

The Texans react

The Texas Department of Insurance did not comment on why the code change was needed. A spokesperson explained that if a health claim is denied, patients can appeal to the insurance company, file a complaint with TDI or another regulatory agency, depending on the type of plan, seek an external review or speak with a lawyer regarding legal options.

Dr. Potter is continuing to perform the surgery and is looking to work with insurance companies and negotiate on behalf of her patients.

“One in eight women will be diagnosed with breast cancer in the United States. So that’s millions of women, right? And then there are women who have the risk of breast cancer and are faced with these difficult decisions and decide whether to have a mastectomy or not. Imagine if a woman who is at risk for breast cancer doesn’t have her preventive mastectomy, because reconstruction of hers is not available to her and so she develops cancer. If we delay and women delay their treatment, we could impact their cancer development. This is so critical that we stop this change now,” Potter said.

She started the Community Breast Reconstruction Alliance, an advocacy group, which pushes to protect access for all patients. Encourage those affected to sign a petition, contact lawmakers and CMS asking for the change to be reversed. She also said that employers should be advised and ask if DIEP flap reconstruction is covered and if they will pay the difference in costs if it is not covered.

Vanessa Vance shared the impact with advocacy groups and lawmakers. (Courtesy of Vanessa Vance)

Vance emailed and called not only his insurer but lawmakers as well. He explained that what he is learning has caused a lot of confusion.

“I’ve met so many people who have already done it, who whisper in my ear and recommend little ways to recover. And then it makes me more confident that this is the right surgery for me. And now it’s just care at what cost. It’s like, how do I get the care that the doctor and I have decided is best for me,” she said.

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