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

Vanessa Vance says she thinks about her family when coping with cancer risk. (courtesy of Vanessa Vance)

AUSTIN, KXAN – Vanessa Vance watched her mother and aunt battle cancer. She often wonders about her chances, especially after having her son.

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

Through genetic testing, she found she was at high risk for ovarian and breast cancer.

“I was able to remove the fallopian tubes,” she said. “So, with a 40% to 60% chance of getting breast cancer, you have a few different pathways you can take, but I think it’s more straightforward for me to actually be a mother of a young child”

Vance has been researching her options and consulting with doctors and surgeons. She is now undergoing mastectomy and DIEP flap reconstruction surgery. It allows patients to use natural tissue from the lower abdomen to create new breasts, rather than using implants.

code change

Vance has insurance, but explained that after a recent insurance code change, she recently discovered that the surgery was only covered for 70 to 90 percent of the time.

“I have my plan. I have my team. My surgeon has been guiding me on what’s the best procedure for me. But now I’m like, ‘Well, how is it going to pay?'” she said.

Women across the state and country share her concerns.

Dr. Elisabeth Potter specializes in DIEP flap surgery and hears from women affected by insurance coverage changes.  (courtesy of Dr. Elizabeth Porter)
Dr. Elisabeth Potter specializes in DIEP flap surgery and hears from women affected by insurance coverage changes. (courtesy of Dr. Elizabeth Porter)

Dr. Elizabeth Porter, a breast reconstructive surgeon who specializes in the procedure, said changes in the DIEP flap code set are associated with other less advanced flap reconstruction procedures.

“There have been some coding changes that equated all types of natural tissue reconstructions, but that’s not the case. That’s the nature of the problem. We originally had surgery that removed the muscles in women, and we’re doing surgery now that keeps women muscles. So from a patient perspective, they’re very different. They’re reimbursed differently. But one insurance company is asking for a change so they can pay the same rate for all types of reconstruction,” Porter explained.

Breast reconstruction is covered by insurance, she added Women’s Health and Cancer Rights Act 1998 These include natural tissue and implants.

this Centers for Medicare and Medicaid Servicesthe government agency that oversees certain billing codes, said the change comes amid American Medical Association and American Academy of Plastic SurgeonsExisting code was modified to include DIEP and other similar advanced flap procedures.

A spokesperson for the agency said CMS has not discontinued medical coverage for DIEP flap procedures.

“As part of an update to the medical procedure coding system, code S2068 has been removed. Removal of this code will not change whether the procedure is covered and will not take effect until December 31, 2024 to ensure providers and payers have sufficient time to adjust their system,” the spokesman added.

CMS said the change reduced the amount of code.

“This change does not require insurers to cover services. Insurers and providers can respond to changes,” the spokesperson added. “CMS is not a party to these negotiations.”

Patients should speak with their insurance company to find out whether DIEP or other services are available in their provider network, CMS said.

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

“Commercial health insurers are not obligated to follow changes in Medicare coding policies,” the association added.

The group of plastic surgeons said it had not called for the change, which was initiated by a private insurer.

“As you are aware, over the past year many commercial health insurers have made explicit changes to their coverage policies for microbreast reconstruction. We are writing to make sure you understand that these changes are triggering troubling reductions in access to such care,” the ASPS president said in a letter to CMS.

A spokesperson further explained that ASPS is committed to educating payers on the value of patient reports, clinical benefits, cost-effectiveness, and the importance of expanding access to these procedures.

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

Out of pocket $50K

Blue Cross and Blue Shield of Texas In a statement, it said it would continue to reimburse the S2068 program 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 sound clinical research, and the effectiveness of various drug treatments is continually reviewed by our medical team in collaboration with physicians and researchers, to produce high-quality and safe outcomes. By doing so, we are becoming good stewards of our members’ healthcare dollars while providing access to a broad selection of providers,” the statement said.

No other insurers have yet responded.

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

“You know, patients immediately find it difficult for their surgeons to get reimbursed for their procedures. I’ve seen women all over the country being asked to pay out of pocket for procedures. This is largely because insurance companies have slashed what they’re willing to pay for these procedures Amount. So we’re seeing women being asked to pay for their breast cancer reconstructive surgery when they should be covered,” Potter explained.

In Texas, patients are required to pay $35,000 to $50,000 out of pocket for procedures, she said.

texans fight back

The Texas Department of Insurance did not comment on why the code change was needed.a spokesperson explained If a health claim is rejectedPatients can appeal to their insurance company, file a complaint with TDI or other regulators, depending on the type of plan, request an external review or discuss legal options with a lawyer.

Dr. Porter is continuing to operate and is trying to work with insurance companies and negotiate on behalf of her patients.

“In the U.S., one in eight women will be diagnosed with breast cancer. That’s millions of women, right? There are still women who are at risk for breast cancer and have to face these tough decisions and decide Whether to have a mastectomy. Imagine if a woman who was at risk for breast cancer didn’t have a preventive mastectomy because she couldn’t have reconstruction, and then she would get cancer. If we delay, and women delay treatment, we could affect their cancer development. It’s very important that we stop this change now,” Porter said.

she started Community Breast Reconstruction Alliance, an advocacy group pushing to protect access for all patients.She encourages those affected sign the petition, Contact Legislators and CMS Request to undo the changes. She also said employers should know and ask if DIEP flap reconstruction is covered, and if not, whether they will pay the difference.

Vanessa Vance has been sharing influence with advocacy groups and lawmakers.  (courtesy of Vanessa Vance)
Vanessa Vance has been sharing influence with advocacy groups and lawmakers. (courtesy of Vanessa Vance)

Vance emailed and called lawmakers as well as her insurance company. She explained that what she learned caused a lot of confusion.

“I met a lot of people who had done it, and they whispered in my ear, gave me little ways to recover. Then it made me more sure that this was the right surgery for me. Now it’s just a matter of paying the price. Like, how do I get the doctor and the care that I think is best for me,” she said.

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