Health insurance coding change impacting a breast reconstruction surgery; what it means for patients
AUSTIN (KXAN) — Vanessa Vance watched her mother and then aunt battle cancer. She often wondered about her own chances, especially after having her son.
"My family has a long history of breast cancer. And so, when I think about my future as a person, I've always told myself, I will be a person who gets breast cancer," she said.
She found out through genetic testing that she is at high risk for ovarian and breast cancer.
"I was able to take out my fallopian tubes," she said. "So, with the 40 to 60% chance for having a risk for breast cancer, you have a couple of different pathways that you can choose from, but I think really being a mother to a young child kind of influences the more directness for me."
Vance has been looking into her options and consulting with doctors and surgeons. She is now in the process of getting a mastectomy and DIEP flap reconstruction surgery. It allows patients to use their natural tissue from the lower abdomen to create a new breast instead of using implants.
Coding Change
Vance has insurance but explained that she recently found out the surgery is only covered at 70 to 90% after a recent insurance coding change.
"I had my plans. I had my team. My surgeons have been guiding me on what's the best surgery for me. But now I'm like, 'well, how is it paid for?'" she said.
Her concerns are shared by women across the state and country.
Dr. Elisabeth Potter, a breast reconstruction surgeon who specializes in the surgery said the change in coding groups DIEP flap with other less advanced flap reconstruction surgeries.
"Some coding changes occurred that equated all types of natural tissue reconstruction as equal, and they really aren't. So that's, that's the essence of the problem. The surgeries that we initially performed removed a woman's muscle, the surgeries that we perform now save a woman's muscle. So, they're very different from a patient's perspective. And they are reimbursed differently. But an insurance company asked for a change so that they could pay the same rate for all types of reconstruction," Potter explained.
She added that breast reconstruction has been 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 the American Society of Plastic Surgeons, revised an existing code to include DIEP and other similarly advanced flap procedures.
A spokesperson with the agency said CMS did not discontinue medical coverage for DIEP flap surgery.
"A code, S2068, was eliminated as part of an update to the medical procedure coding system. The elimination of this code, which – again – does not change whether the surgery will be covered, is not effective until Dec. 31, 2024, to make sure providers and payers have ample time to adjust their systems," added the spokesperson.
CMS said the change reduces the number of codes.
"This change doesn’t dictate services insurance companies cover. Insurers and providers can address changes," added the spokesperson. "CMS is not a party to these negotiations."
CMS said that patients should talk with their insurance companies to understand whether DIEP or other services are available in their provider network.
But AMA explained to KXAN that insurance companies are responsible for payment policies they require for specific medical services.
"Commercial health insurers are under no obligation to follow the change in Medicare’s coding policy," added the association.
The plastic surgeon group said it did not request a change and it was initiated by a private insurer.
"As you know, over the past year, a number of commercial health insurance companies have introduced categorical changes to their coverage policies for microsurgical breast reconstruction. We are writing to ensure your understanding that those changes are triggering disturbing reductions in access to this type of care," said a letter written by the president of ASPS to CMS.
A spokesperson explained further saying that ASPS is dedicated to educating payers on the patient-reported value, clinical benefits, cost-effectiveness, and importance of expanding access to these procedures.
"The goal is to ensure that plastic surgeons can maintain and increase access to these procedures for every woman battling breast cancer," said the spokesperson.
$50K out of pocket
Blue Cross and Blue Shield of Texas said in a statement it will continue to reimburse for the S2068 procedures until further notice from CMS.
"Coverage determinations vary by benefit plan design and could be subject to medical necessity requirements. Coverage decisions are based on sound clinical research with our medical team collaborating with physicians and researchers to constantly review the effectiveness of various medical treatments to produce high-quality and safe outcomes. By doing so, we are being good stewards of our members’ healthcare dollars while providing access to a wide choice of providers," said the statement.
There have been no responses from other insurance companies.
Though the coding change is not scheduled to take place until next year, Dr. Potter said some private health insurers have already made changes to coverage.
"You know, immediately, patients will find that their surgeons are having difficulty getting reimbursed for surgery. I've already seen that women around the country are being asked to pay cash out of pocket for the surgeries. And that's basically because the insurance companies have dramatically cut the amount that they are willing to pay for these surgeries. So, we're seeing that women are being asked to pay for their breast cancer reconstruction surgery when it should be covered," Potter explained.
In Texas, she said patients have been asked to pay $35,000 to $50,000 for the surgery out of pocket.
Texans fighting back
The Texas Department of Insurance had no comment on why the code change was needed. A spokesperson explained that if a health claim is denied, patients can appeal with the insurance company, file a complaint either with TDI or another regulatory agency, depending on what kind of plan it is, ask for an external review or talk to an attorney about legal options.
Dr. Potter is continuing to perform the surgery and is trying 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 have to face these difficult decisions and decide for mastectomy or not. Imagine if a woman who has a risk of breast cancer doesn't have her preventative mastectomy, because her reconstruction isn't available to her and then develops cancer. If we delay, and women delay their treatment, we could impact their cancer development. This is so critically important that we stop this change now," Potter said.
She's started the Community Breast Reconstruction Alliance, an advocacy group, pushing to protect access for all patients. She encourages those impacted to sign a petition, contact lawmakers, and CMS asking for the change to be reversed. She also said employers should be made aware and asked if DIEP flap reconstruction is covered and if they will pay the difference in costs if it's not covered.
Vance has been emailing and calling not only her insurance provider but also lawmakers. She explained that what she's learning has caused a lot of confusion.
"I've met so many people who have already done it, who are kind of whispering in my ear and advising me little ways to recover. And then it makes me more sure that this is the right surgery for me. And now it's just care at what cost. It's like, how can I get the care that the doctor and I have decided is best for me," she said.