Health insurance coding change impacting a breast reconstruction surgery; what it means for patients

AUSTIN (KXAN) – Vanessa Vance watched her mother and aunt battle cancer. He often wondered about his own chances, especially after having his son.

“My family has a long history of breast cancer. So, when I think about my future as a person, I always say to myself, I’m going to be the one with breast cancer,” she said.

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

“I can get my fallopian tubes out,” he said. “So with a 40 to 60% chance of having breast cancer risk, you have a few different paths you can choose, but I think actually being the mother of a young child strikes a lot more candor for me. .”

Vance has considered his options and consulted with doctors and surgeons. She is now in the process of having a mastectomy and DIEP flap reconstruction surgery. This allows the patient to use their natural tissue from the lower abdomen to create a new breast instead of using implants.

Coding Changes

Vance has insurance but explains that he recently found out that surgery is only covered 70 to 90% after the recent insurance code change.

“I have my plan. I have my team. My surgeon has guided me on what surgery is best for me. But now I’m like, ‘well, how do I get paid?’” he said.

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

Dr Elisabeth Potter, a breast reconstructive surgeon specializing in surgery said the DIEP flap coding group changes with other less sophisticated flap reconstructive surgeries.

“Several code changes occurred that equated all types of natural tissue reconstruction as equal, and they are not. So there you have it, that’s the crux of the matter. The surgery we did originally removed the female muscles, the surgery we are doing now saves the female muscles. So, they are very different from the patient’s point of view. And they are replaced differently. But the insurance company asked for a refund so they could pay the same rate for all types of reconstruction,” explained Potter.

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

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

An agency spokesperson said CMS is not stopping medical cover for DIEP flap surgery.

“A code, S2068, was removed as part of an update to the medical procedure coding system. This code deletion, which – again – does not change whether operations will be covered, does not take effect until December 31, 2024, to ensure providers and payers have sufficient time to adapt their systems,” the spokesperson added.

CMS says the change reduces the amount of code.

“This change does not dictate the services covered by insurance companies. Underwriters and providers can handle changes,” the spokesperson added. “CMS is not a party to these negotiations.”

CMS says patients should talk to their insurance company to understand whether DIEP or other services are available in their provider’s network.

But the AMA explained to KXAN that insurers are responsible for the policies on the payments they require for certain medical services.

“Commercial health insurers are under no obligation to keep up with changes in Medicare coding policies,” the association added.

The group of plastic surgeons said it did not call for the change and was initiated by a private insurance company.

“As you may know, over the last year, a number of commercial health insurance companies have introduced categorical changes to their coverage policies for micro breast reconstruction. We are writing to confirm your understanding that the changes are triggering a disruptive reduction in access to this type of care,” said the letter written by the ASPS president to CMS.

A spokesperson elaborated further saying 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 this procedure for every woman battling breast cancer,” the spokesperson said.

$50K out of pocket

Blue Cross and Blue Shield of Texas said in a statement they would continue to reimburse fees for procedure S2068 until further notice from CMS.

“Determination of coverage varies by benefit plan design and may be subject to medical necessity requirements. Coverage decisions are based on good clinical research with our medical team collaborating with doctors and researchers to continuously review the effectiveness of various medical treatments to produce high quality and safe results. By doing so, we are becoming good stewards of our members’ healthcare dollars while providing access to a wide range of provider options,” the statement said.

There has been no response from other insurance companies.

Although the code change isn’t scheduled until next year, Dr. Potter said some private health insurers had made coverage changes.

“You know, pretty soon, patients are going to find that their surgeons are having a hard time getting reimbursed for surgery. I’ve seen women across the country being asked to pay cash for surgeries. And that’s basically because insurance companies have dramatically cut the amount they’re willing to pay for these surgeries. So, we see that women are being asked to pay for their breast cancer reconstructive surgery when it should be covered,” explained Potter.

In Texas, he says patients have been asked to pay $35,000 to $50,000 for out-of-pocket operations.

The Texans fought back

The Texas Department of Insurance didn’t comment on why the code change was necessary. A spokesperson explained that if the health claim is denied, the patient can appeal to the insurance company, file a complaint with either TDI or another regulatory agency, depending on the type of plan, request an external review or speak to an attorney about legal options.

Dr Potter continues to perform surgeries and tries to work with insurance companies and negotiate on behalf of his 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 are at risk for breast cancer and have to face this difficult decision and decide whether or not to have a mastectomy. Imagine if a woman at risk for breast cancer did not have a preventive mastectomy, because her reconstruction was not available to her and it developed cancer. If we delay, and women delay their treatment, we can influence the development of their cancer. It’s so important that we’re stopping these changes now,” said Potter.

She started the Community Breast Reconstruction Alliance, an advocacy group, pushing to protect access for all patients. He encouraged those affected to sign the petition, contact lawmakers, and CMS asked that the changes be rolled back. He also said employers should be informed and asked if DIEP flap reconstruction is covered and whether they will pay the difference in costs if not.

Vance has emailed and called not only his insurance provider but lawmakers as well. He explained that what he had learned had caused a lot of confusion.

“I’ve met so many people who have done it, who whisper in my ear and advise me on small ways to recover. And then made me even more sure that this is the right surgery for me. And now it remains only to care what it costs. It’s like, how can I get the treatment that the doctors and I decide is best for me,” she said.