Insurance change could impact breast cancer recovery process
“Once you hear the words that you have cancer, your life is forever changed.”
NASHVILLE, Tenn. (WSMV) - Breast cancer advocates and survivors hope the government will reverse course on an insurance coding change they believe could put up a roadblock in a survivor’s recovery process.
After a mastectomy, people have several options for reconstruction. Survivors WSMV4 spoke with say the choice is extremely personal.
“It’s my body. I should be able to make the decision of how I’m going to feel comfortable for the rest of my life,” Kimberly Pointer said. “Once you hear the words that you have cancer, your life is forever changed.”
Pointer had reconstruction after her 2020 cancer diagnosis and a double mastectomy.
“Just kind of wiping out the fear of the cancer returning as much as possible,” Pointer said.
Then came the question of reconstruction where Pointer expressed the reason for her decision, “I just wanted to feel as normal as possible.”
One popular option is utilizing an implant. Another option includes utilizing a patient’s own tissue to reconstruct the breast, known as a flap procedure. There are several types, but DIEP flap surgery uses just tissue from the abdomen and spares the muscle.
“It’s really fantastic for patients but it is a very complex operation,” says Dr. Galen Perdikis, the Chair of Plastic Surgery at the Vanderbilt Department of Plastic Surgery.
Doctors and advocates say the choice may become more complicated soon. Starting in 2025, the Centers for Medicare and Medicaid Services (CMS) will only use one billing code for all flap reconstruction procedures.
When asked if breast cancer survivors should be concerned, Dr. Perdikis said, “The bottom line is absolutely yes. You will probably see less opportunity to get the more complex procedures performed.”
Starting in 2025, Medicare will only have one billing code for all flap procedures. Since many private insurers follow Medicare’s lead, others may do the same.
Advocates say this coding change means doctors will get paid less for the newer, more complex DIEP flap procedure. They worry it could lead to patients picking up the tab or fewer doctors performing the procedure and resulting in longer wait times. Those options don’t sit well with doctors.
“If there was one group of patients that deserve to be cared for, it’s this group,” Dr. Perdikis said.
Even though Pointer’s reconstruction is finished, she believes all survivors should get the opportunity to do the research like she did to make the best choice for themselves.
“It’s so annoying for someone to tell you what you should do with your body. We have insurance, we pay for the insurance. You know, it shouldn’t be some trick of the code to decide what makes us feel good as women after we’ve gone through this particular journey, I hate that for every woman that is having to deal with that,” Pointer said.
The American Society of Plastic Surgeons says they’re meeting with CMS on June 1, 2023, in hopes of getting them to re-examine the coding change. They say they’re also lobbying Congress and state legislatures to enact better post-mastectomy coverage requirements.
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