Disfigured patients may be forced to forego surgery

Mar 21 2005

Increasing insurance company denials, restrictions on covered procedures and a new tactic of excluding specific procedures may be forcing some adults and children to live with painful medical conditions or disfigurement. This restrictive access to care contributed to a 10 percent decline in reconstructive plastic surgery procedures in 2004, according to the latest statistics by the American Society of Plastic Surgeons.

The 5.6 million reconstructive procedures performed in 2004 include breast reduction and reconstruction, tumor removal, cleft lip and palate repair, burn care, hand surgery, as well as a host of other procedures that are restorative in nature and often reduce pain.

“This new data is concerning because we don’t believe there are less reconstructive procedures that need to be performed,” said Scott Spear, MD, ASPS president. “We are not positive, but we have some concern the insurance market is suppressing the ability of patients to get needed reconstructive plastic surgery procedures. Going forward, we want to make sure that reconstructive surgery continues to be covered by insurance.”

ASPS Member Surgeons continue to see healthcare providers limit coverage on procedures such as skin lesion and tumor removals. Tumor removal decreased by 8 percent in 2004 and is down 11 percent over the past five years; in addition, hand surgery decreased by 10 percent in 2004 and is down 14 percent over the past five years.

Other procedures being excluded from coverage are breast reduction and some breast reconstruction techniques, which forces patients to make healthcare decisions based on their ability to afford them. Historically, when insurance companies have denied coverage, it was based on a lack of medical necessity; however, patients could appeal the denial and with proper scientific literature and evidence-based studies the denial could be overturned. The new exclusion tactic simply eliminates coverage of specific procedures due to contractual (insurance plan) language with no opportunity to appeal. At least one national company has excluded breast reduction surgery as a covered benefit.

Breast reduction and breast reconstruction procedures dropped 7 percent and 8 percent respectively in 2004. Facing large price tags for these medically necessary procedures, patients may be forced to live with painful medical conditions or disfigurement.

“The increase in denials and the advent of excluding procedures by insurance companies is a possible explanation for the decrease in reconstructive procedures,” said Michael Sadove, MD, American Society of Maxillofacial Surgeons president. “We are working to have better relationships with third-party payers to help them have a greater understanding of the difference between reconstructive and cosmetic procedures. Part of this is an education of third-party payers and the other part is educating the public.”

ASPS offers the most reliable statistics on plastic surgery procedures to date. Since 2003, statistics have been collected through the first online national database for plastic surgery procedures called Tracking Operations and Outcomes for Plastic Surgeons (TOPS). This data combined with the annual survey sent to more than 17,000 board-certified physicians in specialties most likely to perform plastic surgery results in the most comprehensive census on plastic surgery procedures.