WASHINGTON (7News) — Every year, thousands of women undergo reconstructive surgery after a mastectomy, due to breast cancer. But now, health insurance companies are changing the way they reimburse doctors. It's making one of the more effective procedures unaffordable for most women and wielding more power than doctors when it comes to choosing what’s best for patients.
“I have tons of scars, from where the implant went in, where there was an infection and they had to clean that up. I can't stand to look at myself in the mirror, honestly, because it's just a reminder, a constant reminder, said Diane Hager.
Five years ago, Hager found out she had Stage 4 breast cancer.
After a double mastectomy, months of chemotherapy and radiation, and 15 failed reconstruction surgeries, she was left with one option: a procedure called DIEP flap surgery.
“If I can't get it, it's going to be devastating,” said Hager. “It's going to take an emotional toll and I’m going to need help dealing with that.”
The procedure uses a woman’s own fat and blood vessels to reconstruct the breast.
About one in five breast cancer patients gets reconstruction with DIEP flap surgery. But now, because of a code change in medical billing, the surgery that Diane and so many other women were counting on may be out of reach.
“My concern is that fewer women are going to get access to advanced forms of reconstruction,” said Dr Marisa Weiss.
Weiss is a breast radiation oncologist and the founder of breastcancer.org and a breast cancer survivor.
“No one wants mastectomy. No one wants reconstruction,” said Weiss. “So, the reconstruction is their way to get back to feeling more like themselves, to function well, to feel strong again, to re-embrace their lives. And there's really no price you can put on that.”
But it appears the insurance companies have.
Since 2006, doctors have performed DIEP flap surgery using a unique billing code. Billing codes are a standardized language for the healthcare industry. They’re used to describe and classify medical procedures and diagnoses, to ensure accurate billing and reimbursements. But next year, the specific code for DIEP flap surgery disappears and with it, the patient’s coverage for the complicated procedure that can cost $100,000.
Instead, women will be covered under a code for an older, less advanced technique that is 70-90% cheaper to perform.
Weiss said the code change will greatly reduce the number of doctors performing the surgery.
“If the codes are dropped and their payment is substantially reduced, it's unlikely that they're going to keep doing those procedures,” said Weiss. 'Who suffers from that?' It's going to be the women who are trying to have the best outcome.
In advance of the 2024 billing code change, some insurance companies took the procedure off the menu earlier this year and were met with pushback from the breast cancer community.
Cigna, one of the largest health insurers in the United States said, just days ago, that it will delay the policy change, and reprocess claims from surgeons, so they'll be reimbursed at the rate prior to March 12 when the company suspended the code.
Diane Hager said women's voices need to be heard.
"The insurance company weighed in way more than they should have throughout my entire treatment. My doctor was on the phone spending time that she did not have, to get them to agree to certain tests that I needed," Hager said. "The insurance companies should not have the power to determine what your treatment, or surgery, or what the next step's going to be."
And advocates said in a surprising turn of events, the Centers for Medicare and Medicaid Services (CMS), the government agency that determines code changes, has announced that reconsidering this code change will be the number-one agenda item for their June 1 public meeting.
Sources told us that depending on the outcome, it could mean an extension of the code or a complete reversal of its elimination. CMS will be accepting written comments up until the meeting. Written statements will be accepted via email to CMS up until the day of the meeting.
The meeting agenda is available here. You may attend the meeting via Zoom and if you wish to address the panel, you must register here by May 16.
In the wake of Cigna temporarily reactivating the code for DIEP flap surgery, the company provided us with the following statement:
"We are committed to ensuring that our customers have affordable coverage and access to the full range of breast reconstruction procedures and to quality surgeons who perform these complex surgeries. While our updated guidance for free flap breast reconstruction claims will not result in reduced reimbursements for most surgeons, we are delaying its implementation to give providers more time to prepare for this industry-wide change as well as offer the American Medical Association an opportunity to develop additional coding guidance to address concerns raised by some surgeons."
If you are considering DIEP flap reconstruction surgery, check with your insurance company to make sure they have not eliminated the code for the procedure. The code for Deep Inferior Epigastric Perforation Flap breast reconstruction is S2068.