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Insurance Code Change Could Impact Breast Reconstruction – Details Here

Breast Reconstruction Surgery Insurance Code Change

The ability to undergo a surgical procedure in order to treat breast cancer might soon become more difficult for some patients. In February of this year, news outlets reported that a popular breast reconstruction procedure, known as DIEP flap surgery, was scheduled to be impacted by some insurance companies making the decision to stop reimbursing some, or all, of the cost of the treatment.

Why did this happen? Keep reading for the answer.

Insurance Code Change – How it is Impacting Breast Reconstruction Surgery

Insurance Code Change Impact on PatientThe reason behind this decision is related to changes made by the federal agency that oversees health insurance, the Centers for Medicare and Medicaid Services (CMS). This agency has dropped the specific billing code for DIEP flap surgery. The change is scheduled to take place in 2024 and it means the procedure will be reimbursed at a lower rate than in the past. Unfortunately, DIEP flap is more expensive than other types of breast reconstruction procedures so it will make it harder for patients to pay for their treatment.

The billing code change has resulted in an outcry from cancer patients and survivors who pointed out that no one plans on getting breast cancer which means their health options should not be changed to the point that it penalizes a person for having the condition.

Insurance Code Change – Immediate Impact on Patients

Even though the code change is not scheduled to happen until 2024, there have been reports that at least three major insurance companies quickly stopped covering a DIEP flap procedure on a partial or full basis. Two of these insurance companies reversed their decision after a public backlash and have placed a “pause” on their decision for the moment.

The cost of DIEP flap surgery can cost tens of thousands of dollars and the part that is not covered by insurance will need to be paid out of pocket by the patient. If this is the case, there are many patients who will not be able to afford the procedure if they have to pay for the surgery.

Insurance Code Change – Why the Change Might Not Happen

After multiple campaigns organized and executed by cancer patients and survivors, CMS is now reconsidering the changes they announced regarding the coding change. The campaigns highlight the fact that once insurance companies stop this coverage in 2024, women across the country will find themselves in a difficult position of trying to pay for the procedure.

There are multiple lawmakers who are urging CMS to reverse its decision due to the concerns of many women and medical professionals about female patients potentially losing their access to the latest breast reconstruction techniques after having breast cancer.

Insurance Code Change – How Patients Would be Covered

The proposed federal change in billing codes for medical insurance might mean that insurance companies will only reimburse for older surgical procedures that are less advanced in how they are performed. If they will (potentially) only reimburse for older techniques, patients might not be able to afford to pay for more advanced medical techniques.

In years past, insurance companies were mandated to pay for breast reconstruction surgery after cancer as well as surgery on the opposite breast of the patient in order to provide a symmetrical appearance to the breasts.

There is also some concern that female patients will not have the same options as women in the past since there is a plan to combine all of the different types of flap breast reconstruction procedures together under one single insurance cost code by the end of next year.

In addition to female patients, there are also some surgeons who are concerned about their current and future patients. They are concerned if the insurance codes change, they will not be able to bill insurance companies for more advanced types of reconstructive surgery as they will not be able to cover their own costs.

In other words, female patients will have much less access to the latest surgical procedures. If they are able to undergo the latest surgical breast reconstruction procedures, they might have to wait longer to have a procedure.

Even though a final decision about DIEP flap surgery has not been made and will likely not be made without additional discussions and changes, the Centers for Medicare and Medicaid Services (CMS) will continue to reconsider the changes they have already announced for next year.

Patients who are interested in having breast reconstruction surgery are advised to schedule an appointment with a board-certified and trained surgeon who can perform a thorough medical examination of the person. The doctor will be able to determine the current health of the patient as well as the extent of the breast cancer experienced by the person. Once the doctor makes a diagnosis of the health of the patient, the surgeon can advise the patient if DIEP flap surgery is the best medical option to address their individual health needs.

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