Insurance coding changes will limit access to DIEP flap breast reconstruction surgery — this is NOT okay!

When I was recently alerted to changes in insurance coding (thank you, Terri) and how this change could potentially and significantly limit breast cancer patients’ access to breast reconstruction options, I knew this post had to be written.

As you likely know, when you have any medical procedure, doctors submit corresponding codes when billing insurance companies, which may — or may not — cover part, or all of the cost.

That’s a lot of codes out there and a lot of power given to insurance companies. Too much power. But that’s a different post.

In 2019, the decision was made (by whom exactly and why, I’m not entirely sure; I have not been able to track down this piece of the puzzle) to change coding for some breast reconstruction procedures including DIEP flap. Basically, and as I understand it, all flap breast reconstruction procedures would/will be put under one master code — eliminating the specific code(s) for DIEP flap and other complex flap surgeries. 

This makes no sense. It’d be like putting all heart surgeries under one master code. Obviously, there are varied heart procedures and surgeries. It’s the same with breast reconstruction flap surgeries. They are not all alike.

The more complex surgeries like DIEP (there are others) up to now, have had their own special codes. These procedures require highly skilled microsurgeons to perform them, and the surgeries are much lengthier as well. This, of course, makes them more expensive and also makes insurers less willing to offer coverage.

So, yes, it’s all about insurers bottom line — NOT about women’s access, and this is not okay!

This change is slated to go into effect at the end of 2024. However, some insurers are already taking advantage of this “out” and opting to say “no” to DIEP surgeries right now. Yes, of course, they are.

Breast Reconstruction Option Basics

The most commonly preformed breast reconstruction utilizes implants — either saline or silicone filled. Typically, this requires two surgeries. Tissue expanders are placed immediately after a mastectomy and filled over time. At a later date, the expanders are swapped out, and the implants are put in their place.

Another option is aesthetic flat closure. This option is the best choice for some women for many and varied reasons. Unbelievably, some insurance companies still balk at covering this procedure that is best done by a plastic surgeon or a breast surgeon skilled in this specific procedure.

Yet another option, is using a woman’s own tissue to rebuild/create a permanent, more natural feeling breast. This type of surgery is also referred to as an autologous procedure. DIEP Flap breast reconstruction is one option in the autologous category. Others include: SIEA, GAP, TRAM, and Latissimus.

Yours truly has first-hand knowledge and experience with implants and DIEP. Most recently, I opted for DIEP flap surgery following an implant rupture and subsequent decision to remove both implants and go the autologous route.

You might want to read: What’s it like six months post DIEP flap surgery and/or What’s it like one year post DIEP?

There is no way I would’ve been able to pursue this option (DIEP) had insurance (in my case Medicare) not covered this cost.

On a side note, following phase 2 of my DIEP flap (there is usually, but not always, a phase 2), Medicare denied coverage of a significant part of my claim. That resulted in lots of stress. I appealed — extra work and more stress — while recovering, I might add. Luckily, a favorable outcome eventually came about after a second appeal. I’ll share more about how to appeal in a later post.

Bottom line, I want any woman to have access to ALL breast reconstruction options, including these advanced procedures like DIEP. Such decisions do NOT belong in the hands of insurers.

If you want to read more articles like this one, Click Here.

Back to the coding changes…

Who’s in charge of coding?

The Centers for Medicare and Medicaid services oversees coding, but according to a CBS news piece, the CMS claims this coding change happened after the American Medical Association and plastic surgeons asked for it. Doctors groups say the insurance companies asked for it in order to lower their reimbursement costs. (I tend to believe the latter.)

This feels like major finger-pointing to me. It also seems like a simple fix. Just get together and decide to keep coding as it was. It also feels a little bit like it was done “quietly”, so folks might not notice.

In the meantime, this is causing considerable angst for women who are facing mastectomies and trying to make huge, life-altering decisions regarding breast reconstruction options. Some insurers have already started saying “no” to covering DIEP flap surgeries. Others are sure to follow suit — or will try to.

This added turmoil, uncertainty, and stress is completely unnecessary and unacceptable. There is enough to deal with upon learning you have breast cancer and that you need a mastectomy. Same deal for those undergoing prophylactic mastectomies.

Women’s reconstruction options should not be messed with.

Before the Women’s Health and Cancer Rights Act, a Federal law passed in 1998, breast reconstruction wasn’t considered a necessary part of breast cancer treatment. Insurance companies were not required to cover it.

And guess what?

They didn’t.

After passage of the WHCRA, that changed. Following its passage, coverage for the following must be provided:

• All stages of reconstruction of the breast on which the mastectomy has been performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• Prostheses and treatment of physical complications of all stages of the mastectomy, including lymphedema.

There are some gray areas. Yes, of course, there are. To read more, click here. If you’re considering breast reconstruction, be sure there are no gray areas that impact your situation.

This coding change debacle needs to be fixed!

It’s completely unacceptable to implement code changes that will decrease a woman’s breast reconstruction options.

Why should women have access to fewer reconstruction options?

Taking away an option women have had feels wrong.

And, it’s an easy fix. Just reverse the changes.

What can you and I do to see that this happens?

As always, together our voices are stronger. So, even if you aren’t personally impacted, your help is needed.

Advocate — How?

1. Write to your legislators telling them to get this code change reversed.

Read ways to advocate and find sample letters you can copy and paste into your emails to legislators at Elisabeth Potter, MD’s website.

2. Learn more and speak out.

A must-read article via @breastcancer.org titled: Insurance Companies Set to End Coverage for DIEP Flap Surgery.

Read this important opinion piece by Dr. Minas Chrysopoulo via PRMA Plastic Surgery titled: This Simple Coding Change Could Kill Access to DIEP Flap Breast Reconstruction for Thousands of Americans His piece also contains sample letters to send to your legislators.

Read this excellent article, DIEP Flap Insurance Coverage at Risk: Urgent Advocacy Issue, by fellow blogger/advocate, Jennifer Douglas.

Another article to check out, appropriately title: Not Quiet, Please via Lisa Valentine.

Learn more about all things DIEP at DIEP C Foundation.

3. Share your story, or that of someone you know, on social media or wherever you are comfortable.

4. Share this post. (Thank you!)

5. Sign this petition. (I did.)

Please consider an action YOU are willing and able to take that will make a difference for someone else in the maze that is breast cancer.

Because every woman deserves access to advanced breast reconstruction options — not just those who can afford it.

Thank you for sharing this post!

Have you, or has someone you know, had DIEP flap surgery, or one of the other autologous surgeries?

Do you think these advanced breast reconstruction surgeries should be covered by insurers? Why or why not?

What is an action you are willing to consider taking to get this decision reversed?

Will you share this post and perhaps the others mentioned above?

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