ROANOKE TIMES
Copyright (c) 1997, Roanoke Times
DATE: Monday, February 10, 1997 TAG: 9702100093
SECTION: VIRGINIA PAGE: A-1 EDITION: METRO
SOURCE: SANDRA BROWN KELLY AND DEBRA GORDON LANDMARK NEWS SERVICE
CANCER PATIENTS say it's critical to total recovery. But increasingly, Virginia insurance companies won't cover the bills.
Insurance companies in Virginia are refusing to pay for some stages of breast reconstruction, infuriating women and their doctors and prompting state legislation that would mandate coverage.
The goal of breast reconstruction is to enable a woman to look as normal as possible, plastic surgeons say. In about 25 percent of cases, that involves not only rebuilding the breast that was removed, but also lifting, reducing or enlarging the natural breast to match the reconstructed one.
But many insurance companies, including the state's largest insurer, Trigon Blue Cross Blue Shield, often call surgery to restore symmetry ``cosmetic'' and refuse to pay for it.
Some also won't pay for procedures to correct complications from the original surgery, such as scarring, or to mold the nipple and darken the skin around it to create an areola.
``I was just livid,'' said Gail Smith of Martinsville, whose symmetry reconstruction was denied by her insurance company last spring. ``I didn't choose for this to happen. Everything I've read said that symmetry is an important part of the surgery.''
She complained to state Sen. Roscoe Reynolds, D-Henry County, who introduced legislation that would require payment for symmetry procedures.
The legislation also is needed to ward off tighter restrictions doctors fear are coming from insurance companies, a Roanoke plastic surgeon said.
Dr. Enrique Silberblatt said that so far in his experience most insurance companies have been willing to pay for the additional surgery to adjust the natural breast to match the reconstructed one. But he said he fears that will change unless legislation requires the insurers to pay.
Some insurance companies already have come out with what he calls "very unfair parameters" for paying for breast reductions, including requiring a woman who is not even obese to lose weight first, he said.
Denying payment for the breast match-up surgery for cancer victims "is going to be the next thing on the list," he said.
A survey by the American Society of Plastic and Reconstructive Surgeons, which represents nearly all board-certified plastic surgeons in the country, found that 84 percent of its members had up to 10 patients denied insurance coverage for breast reconstruction in 1995.
Forty-three percent had been denied coverage of symmetry procedures and nearly 20 percent had been denied coverage for changes made after the initial surgery.
``Getting approval for the opposite breast surgery and the areola never was a problem five years ago,'' said Norfolk plastic surgeon Lawrence Colen. ``Now it's a routine problem.''
Women who have had breast reconstruction say the entire procedure - including any follow-up surgery - is necessary for their emotional well being, already devastated by the diagnosis of cancer.
About 182,000 women will be diagnosed with breast cancer this year, 4,500 in Virginia. Last year, 85,000 women nationally received mastectomies, with about 26,000 choosing reconstruction.
There are two main methods of reconstruction: man-made implants and autologous reconstruction, in which the woman's own tissue is used to rebuild the breast.
Implants are the simpler and less expensive procedure, costing about $2,400 for the surgeon's fee and primarily done on an outpatient basis. But they have drawbacks. Some plastic surgeons will not use implants if the woman needs follow-up radiation,
"It's an area of controversy," Silberblatt said.
Radiation can cause tissue around the implant to get hard, he said.
Autologous reconstruction, commonly called a TRAM - transverse rectus abdominus myocutaneous - in which fat from a woman's abdomen or back is used to shape a new breast, provides a more natural-looking breast, doctors say. But the six- to eight-hour operation, including follow-up care, costs about $6,400 for the surgeon's fee and requires an overnight stay in the intensive care unit, as well as several days in the hospital.
Silberblatt said he probably swims against the tide in that he tries to use implants as much as possible because of their lower cost and because the autologous reconstruction involves extensive surgery with higher possibilities for complications.
"I try to get most for least, and implants work in most patients pretty well," he said.
However, a breast created with an implant usually won't match up with the breast on the other side, especially if the unaffected breast is quite saggy, he said.
This means the other breast has to be "pulled up," Silberblatt said.
In cases where symmetry isn't covered, some women won't even have the initial reconstruction, said Mary Jo Ellis Kahn, of the Virginia Breast Cancer Foundation.
Age, or even severity of illness, has nothing to do with a woman's desire for reconstruction, said plastic surgeon Christine Horner-Taylor, of Edgewood, Ky. Horner-Taylor is founder of the national Breast Reconstruction Advocacy Project, or BRA. The grass-roots project tries to get legislation passed to cover all aspects of reconstruction.
A woman's identity is connected with her breasts, she said. ``It's a feeling of wholeness. It's all about how a woman feels about her sexual identity.'' Fear of losing a breast, she said, is one reason women spurn early breast-cancer detection programs.
Horner-Taylor started her organization in 1995 after a Kentucky insurance company told her that a woman's breast was ``an organ with no function'' and refused to cover the initial reconstruction.
``That's when I went insane,'' Taylor said. ``I said, `You will pay and everyone will pay,' and started organizing the whole country.''
Thirteen states have laws mandating coverage of breast reconstruction, although not all cover symmetry surgery and other follow-up procedures. The Virginia bill has been referred to a committee that studies mandated benefits, and no action will be taken on it until next year's General Assembly session.
By the time it is considered, federal legislation may already be passed. Two bills introduced in January, one by Rep. Anna Eshoo, D-Ca., and one by a bipartisan coalition of House and Senate members, including Sen. Alfonse D'Amato, R-N.Y., would require coverage of all aspects of breast reconstruction. Sen. Ted Kennedy, D-Mass., is expected to introduce a third bill.
The insurance trade group, Health Insurance Industry of America, opposes mandates of any kind. ``They tend to drive up the cost of health coverage,'' spokesman Richard Coorsh said. He said most plans in his organization cover breast reconstruction, although he didn't know if that included follow-up procedures like those to restore symmetry.
No matter, having a breast reconstructed after breast cancer surgery is not something that should be decided for a woman, Silberblatt said.
"It's something you should decide for yourself, like many things in health care," he said.
LENGTH: Long : 128 lines ILLUSTRATION: PHOTO: ROGER HART/Staff. Gail Smith, a Martinsville Highby CNBteacher, complained to state Sen. Roscoe Reynolds, D-Henry County,
when her insurance company refused to pay for her reconstructive
surgery. color. KEYWORDS: GENERAL ASSEMBLY 1997