The federal government is reconsidering a decision that breast cancer patients, plastic surgeons, and members of Congress have protested would limit women\u2019s options for reconstructive surgery.<\/p>\n

On June 1, the Centers for Medicare & Medicaid Services plans to reexamine how doctors are paid<\/a> for a type of breast reconstruction known as DIEP flap, in which skin, fat, and blood vessels are harvested from a woman\u2019s abdomen to create a new breast.<\/p>\n

The procedure offers potential advantages over implants and operations that take muscle from the abdomen. But it\u2019s also more expensive. If patients go outside an insurance network for the operation, it can cost more than $50,000. And, if insurers pay significantly less for the surgery as a result of the government\u2019s decision, some in-network surgeons would stop offering it, a plastic surgeons group has argued.<\/p>\n

The DIEP flap controversy, spotlighted by CBS News in January<\/a>, illustrates arcane and indirect ways the federal government can influence which medical options are available \u2014 even to people with private insurance. Often, the answers come down to billing codes \u2014 which identify specific medical services on forms doctors submit for reimbursement \u2014 and the competing pleas of groups whose interests are riding on them.<\/p>\n

Medical coding is the backbone for \u201chow business gets done in medicine,\u201d said Karen Joynt Maddox<\/a>, a physician at Washington University School of Medicine in St. Louis who researches health economics and policy.<\/p>\n

CMS, the agency overseeing Medicare and Medicaid, maintains a list of codes representing thousands of medical services and products. It regularly evaluates whether to add codes or revise or remove existing ones. Last year, it decided to eliminate a code that has enabled doctors to collect much more money for DIEP flap operations than for simpler types of breast reconstruction.<\/p>\n

In 2006, CMS established an \u201cS\u201d code \u2014 S2068 \u2014 for what was then a relatively new procedure: breast reconstructions with deep inferior epigastric perforator flap, or DIEP flap. S codes temporarily fill gaps in a parallel system of billing codes known as CPT codes, which are maintained by the American Medical Association, a physician group.<\/p>\n

Codes don\u2019t dictate the amounts private insurers pay for medical services; those reimbursements are generally worked out between insurance companies and medical providers. However, using the narrowly targeted S code, doctors and hospitals have been able to distinguish DIEP flap surgeries, which require complex microsurgical skills, from other forms of breast reconstruction that take less time to perform and generally yield lower insurance reimbursements.<\/p>\n

CMS announced in 2022 that it planned to eliminate the S code at the end of 2024 \u2014 a move some doctors say would slash the amount surgeons are paid. (To be precise, CMS announced it would eliminate a series of three S codes for similar procedures, but some of the more outspoken critics have focused on one of them, S2068.) The agency\u2019s decision is already changing the landscape of reconstructive surgery and creating anxiety for breast cancer patients.<\/p>\n

Kate Getz, a single mother in Morton, Illinois, learned she had cancer in January at age 30. As she grappled with her diagnosis, she said, it was overwhelming to think about what her body would look like over the long term. She pictured herself getting married one day and wondered \u201chow on earth I would be able to wear a wedding dress with only having one breast left,\u201d she said.<\/p>\n

She thought a DIEP flap was her best option and worried about having to undergo repeated surgeries if she got implants instead. Implants generally need to be replaced every 10 years or so. But after she spent more than a month trying to get answers about how her DIEP flap surgery would be covered, Getz\u2019s insurer, Cigna, informed her it would use a lower-paying CPT code to reimburse her physician, Getz said. As far as she could see, that would have made it impossible for Getz to obtain the surgery.<\/p>\n

Paying out-of-pocket was \u201cnot even an option.\u201d<\/p>\n

\u201cI\u2019m a single mom. We get by, right? But I\u2019m not, not wealthy by any means,\u201d she said.<\/p>\n

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Cost is not necessarily the only hurdle patients seeking DIEP flaps must overcome. Citing the complexity of the procedure, Getz said, a local plastic surgeon told her it would be difficult for him to perform. She ended up traveling from Illinois to Texas for the surgery.<\/p>\n
The government\u2019s plan to eliminate the three S codes was driven by the Blue Cross Blue Shield Association, a major lobbying organization for health insurance companies. In 2021, the group asked CMS to discontinue the codes, arguing that they were no longer needed because the American Medical Association had updated a CPT code to explicitly include DIEP flap surgery and the related operations, according to a CMS document<\/a>.<\/p>\n
For years, the American Medical Association advised doctors that the CPT code was appropriate for DIEP flap procedures. But after the government\u2019s decision, at least two major insurance companies told doctors they would no longer reimburse them under the higher-paying codes, prompting a backlash.<\/p>\n
Physicians and advocacy groups for breast cancer patients, such as the nonprofit organization Susan G. Komen<\/a>, have argued that many plastic surgeons would stop providing DIEP flap procedures for women with private insurance because they wouldn\u2019t get paid enough.<\/p>\n
Lawmakers from both parties have asked the agency to keep the S code, including Rep. Debbie Wasserman Schultz (D-Fla.) and Sen. Amy Klobuchar (D-Minn.), who have had breast cancer, and Sen. Marsha Blackburn (R-Tenn.).<\/p>\n
CMS at its June 1 meeting<\/a> will consider whether to keep the three S codes or delay their expiration.<\/p>\n
In a May 30 statement, Blue Cross Blue Shield Association spokesperson Kelly Parsons reiterated the organization\u2019s view that \u201cthere is no longer a need to keep the S codes.\u201d<\/p>\n
In a profit-driven health care system, there\u2019s a tug of war over reimbursements between providers and insurance companies, often at the expense of patients, said Joynt Maddox, the Washington University physician.<\/p>\n
\u201cWe\u2019re in this sort of constant battle\u201d between hospital chains and insurance companies \u201cabout who\u2019s going to wield more power at the bargaining table,\u201d Joynt Maddox said. \u201cAnd the clinical piece of that often gets lost, because it\u2019s not often the clinical benefit and the clinical priority and the patient centeredness that\u2019s at the middle of these conversations.\u201d<\/p>\n
Elisabeth Potter, a plastic surgeon who specializes in DIEP flap surgeries, decided to perform Getz\u2019s surgery at whatever price Cigna would pay. <\/p>\n
According to Fair Health, a nonprofit that provides information on health care costs, in Austin, Texas \u2014 where Potter is based \u2014 an insurer might pay an in-network doctor $9,323 for the surgery when it\u2019s billed using the CPT code and $18,037 under the S code. Those amounts are not averages; rather, Fair Health estimated that 80% of payment rates are lower than or equal to those amounts.<\/p>\n
Potter said her Cigna reimbursement \u201cis significantly lower.\u201d<\/p>\n
Weeks before her May surgery, Getz received big news \u2014 Cigna had reversed itself and would cover her surgery under the S code. It \u201cfelt like a real victory,\u201d she said.<\/p>\n
But she still fears for other patients.<\/p>\n
\u201cI\u2019m still asking these companies to do right by women,\u201d Getz said. \u201cI\u2019m still asking them to provide the procedures we need to reimburse them at rates where women have access to them regardless of their wealth.\u201d<\/p>\n
In a statement for this article, Cigna spokesperson Justine Sessions said the insurer remains \u201ccommitted to ensuring that our customers have affordable coverage and access to the full range of breast reconstruction procedures and to quality surgeons who perform these complex surgeries.\u201d<\/p>\n
Medical costs that health insurers cover generally are passed along to consumers in the form of premiums, deductibles, and other out-of-pocket expenses.<\/p>\n
For any type of breast reconstruction, there are benefits, risks, and trade-offs. A 2018<\/a> paper published in JAMA Surgery found that women who underwent DIEP flap surgery had higher odds of developing \u201creoperative complications\u201d within two years than those who received artificial implants. However, DIEP flaps had lower odds of infection than implants.<\/p>\n
Implants carry risks of additional surgery, pain, rupture, and even an uncommon type of immune system cancer.<\/p>\n
Other flap procedures that take muscle from the abdomen can leave women with weakened abdominal walls and increase their risk of developing a hernia.<\/p>\n
Academic research shows that insurance reimbursement affects which women can access DIEP flap breast reconstruction, creating a two-tiered system for private health insurance versus government programs like Medicare and Medicaid. Private insurance generally pays physicians more than government coverage, and Medicare doesn\u2019t use S codes.<\/p>\n
Lynn Damitz, a physician and board vice president of health policy and advocacy for the American Society of Plastic Surgeons, said the group supports continuing the S code temporarily or indefinitely. If reimbursements drop, some doctors won\u2019t perform DIEP flaps anymore, she said.<\/p>\n
A study published in February<\/a> found that, of patients who used their own tissue for breast reconstruction, privately insured patients were more likely than publicly insured patients to receive DIEP flap reconstruction.<\/p>\n
To Potter, that shows what will happen if private insurance payments plummet. \u201cIf you\u2019re a Medicare provider and you\u2019re not paid to do DIEP flaps, you never tell a patient that it\u2019s an option. You won\u2019t perform it,\u201d Potter said. \u201cIf you take private insurance and all of a sudden your reimbursement rate is cut from $15,000 down to $3,500, you\u2019re not going to do that surgery. And I\u2019m not saying that that\u2019s the right thing to do, but that\u2019s what happens.\u201d<\/p>\n
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