Insurance change expected to limit breast cancer reconstruction surgery options

A billing issue may limit the type of reconstructive surgery for women who undergo mastectomies.
Reconstructive surgery becomes insurance problem
Published: Feb. 16, 2023 at 6:15 PM CST
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BROWN COUNTY, Wis. (WBAY) - A Brown County plastic surgeon is worried that a recent change in insurance could impact future breast cancer reconstruction surgeries.

A billing issue may limit the type of reconstructive surgery for women who undergo mastectomies.

Federal law requires insurance companies to cover a woman’s reconstructive surgery after having a mastectomy, but it doesn’t specify which type is covered.

A certain type of breast reconstruction surgery is gaining in popularity. It’s called Diep Flap breast reconstruction where a plastic surgeon uses the tissue, normally thrown away in a tummy tuck, to build a breast.

“It is great for patients who for some reason have failed reconstruction, who may have had radiation damage to this area, or just want to avoid implant reconstruction because it requires more maintenance,” said Dr. Karri Adamson, a plastic surgeon with BayCare Clinic.

Dr. Adamson performs a reconstruction surgery every week. Last year, she completed 40 Diep Flap reconstruction surgeries.

“So, it’s fairly common even in a relatively smaller community like the Green Bay Area and would be devastating for a lot of patients,” said Dr. Adamson.

Centers of Medicaid and Medicare Services, or CMS, recently changed a billing code. It puts Diep Flap reconstruction surgery into the same category as more traditional types of breast reconstruction surgeries.

“So, the extra complexity of dissection, equipment, requiring an extra surgeon are not charged or reimbursed,” said Dr. Adamson.

This change led some surgeons to drop the procedure, which ultimately impacts patient care.

“The fear is that the option of Diep Flap breast reconstruction won’t be an option for all patients or will be harder to obtain either financially or even to find a location that offers,” said Dr. Adamson.

Dr. Adamson is able to continue offering the procedure at her BayCare Clinic, but she said it’s only a matter of time before other insurance companies follow the lead of CMS.

“It’s definitely becoming a problem in other parts of the country, and it seems to eventually trickle throughout the entire country,” said Dr. Adamson. “I do think it’s a better option for a lot of patients so it’s scary that it could possibly not be an option in the future.”

Dr. Adamson, along with other plastic surgeons across the nation, is contacting state representatives in Congress and she is asking patients to do the same.

“I think that breast cancer impacts so many people, almost everyone has either gone through this with a friend or family member or themselves. So, it’s just a matter of patients even being aware that this is happening, and then knowing that they can do something about it. They can reach out. I think it impacts so many people that we could make a difference for sure,” said Dr. Adamson.

Dr. Adamson acknowledges that insurance is complicated, so if this is affecting you, start asking questions. A good place to start is with your doctor and insurance company.