AUSTIN, Texas — A change in billing codes could limit reconstruction choices for breast cancer patients needing a mastectomy.
Because of recent changes to insurance, this can affect patients’ access to modern reconstruction techniques used during a meatotomy surgery.
According to Dr. Elisabeth Potter, an Austin-based breast surgeon, in order for a patient to have a surgery, you have to go through the process of seeing a doctor and then having insurance cover that surgery under the Women’s Health and Cancer Rights Act.
However, what’s changed is the way doctors, insurance companies and patients communicate about what surgery a patient is choosing.
“The change in communication between patients and doctors and insurance companies is basically that patients are no longer able to clearly ask for modern breast reconstruction,” Potter said. “They are only able to ask for a breast reconstruction in general, and the insurance companies have said that all types of breast reconstruction are basically equal when they’re not.”
With this change, the most modern reconstructions are going to become unavailable to patients who need access to their insurance. Modern breast reconstruction will always be available, but it’s going to become financially unavailable to the vast majority of patients.
For a patient who is seeking breast reconstruction, Potter said they need to know to ask for the most modern type of breast reconstruction, specifically a surgery that does not remove muscle and cause a disability. On the other hand, the surgery the government is willing to pay for is a surgery that removes muscle.
“The surgery that women deserve is a surgery that saves their muscle so that they can go and thrive in their long life, that you’re going to live after this diagnosis. So a woman needs to ask for a DIEP flap breast construction or a modern reconstruction,” Potter said.
Currently there are still some surgeons out there performing the modern surgeries through insurance, Potter said.
“The intent of the law was to provide for the best breast reconstruction for women facing breast cancer. So I think that the law is on our side. I think that the intent of the law is on our side and doctors want to do the right thing,” Potter said. “Now we just have to meet back at the table and recognize that there’s been a miscommunication and sort this out.”
Potter said she learned about this change in policy in December 2020, but went into high gear in April 2022 when UnitedHealthcare announced it would no longer allow the use of the code for modern breast reconstruction.
“We need the American Medical Association and the American Society of Plastic Surgeons to sit down together and be willing to say, ‘We made a mistake. We need to walk this back.’ Because there have been unintended consequences of this change,” Potter said. “And that’s not a bad statement. I’m not blaming anyone. I’m just saying, ‘Guys, let’s all meet at the table and make the change.'”
According to Potter’s advocacy website, there are steps to take now to protect medical coverage for natural breast reconstruction, including raising awareness about changes to access and insurance coverage of breast reconstruction and sharing your personal experience with breast reconstruction.
More information on how to advocate can be found here.