AMA Supports Insurance Coverage of Children's Deformities; Over Half of Plastic Surgeons Surveyed Report Coverage Denials
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Dallas (December 10, 1997) -- The American Medical Association (AMA) passed a resolution today introduced by the American Society of Plastic and Reconstructive Surgeons (ASPRS) and other concerned organizations aimed at ensuring insurance coverage of procedures associated with childhood deformities, disfigurements and congenital defects.
The American Society of Maxillofacial Surgeons, the American Association of Plastic Surgeons, the American Academy of Child and Adolescent Psychology, the American College of Surgeons, the American Pediatric Surgical Association and the American Society for Surgery of the Hand worked with ASPRS to introduce the resolution.
ASPRS led the initiative to seek an AMA resolution because of feedback from its members that gaining insurance coverage of procedures associated with childhood deformities, disfigurements and congenital defects was becoming increasingly difficult.
In a recent survey conducted by ASPRS, more than half of plastic surgeons polled reported insurance denial or trouble obtaining coverage of procedures for deformities, disfigurements and congenital defects in children.
"I struggle personally every day with denial for reimbursement for these deformities, and while the findings of the ASPRS survey are alarming, they are not surprising," says Dennis Lynch, MD, president of ASPRS.
"Insurance coverage denial for pediatric plastic surgery procedures is a symptom of the broader issues plaguing the state of medical care in this country today," says Dr. Lynch. "From decreased hospital stays to an increased number of insurance denials for procedures traditionally covered, insurance companies rather than medical professionals are determining the quality of patient care."
"Who should be determining what is ëmedically necessary,' -- insurance companies or physicians?" adds Dr. Lynch.
The AMA resolution states that:
AMA declares that treatment of a minor child's congenital or developmental deformity or disorder due to trauma or malignant disease should be covered by all insurers; and
Such coverage shall include treatment, which in the opinion of the treating physician, is medically necessary to return the patient to a more normal appearance (even if the procedure does not materially affect the function of that body part); and
That such insurability should be portable, i.e., not denied as a pre-existing condition if the patient's insurance coverage changes before treatment has been either initiated or completed; and
The AMA will publicize the nature and prevalence of this problem and identify appropriate remedies, up to and including legal or legislative action.
AMA Board of Trustees member Edward Hill, MD, of Tupelo, Miss., notes that plastic surgery that allows a child to have a normal appearance--even if it doesn't improve bodily function-- is important for social acceptance.
"What about mental function? What about psychological function?" says Dr. Hill. "Can you imagine the life of a child with a gross deformity, which can be repaired, as far as the mental health concerns for the rest of their lives? We have some real concerns with that."
When the AMA passes a resolution, it officially goes on record in support of an issue, in this case insurance coverage for procedures associated with childhood deformities, disfigurements and congenital defects.
"ASPRS is pleased the AMA shares our concerns and supports our endeavors on this issue," says Dr. Lynch.
ASPRS' initiatives include alerting the public to the problem of insurance denials and educating insurance companies about what constitutes reconstructive versus cosmetic surgery. In addition, ASPRS will work with other patient and physician organizations to pass legislation to ensure coverage for childhood deformities, disfigurements and congenital defects.
According to the ASPRS survey, the most often denied childhood deformities, disfigurements and congenital defects procedures are associated with: 1) nose reshaping for congenital nasal deformities related to cleft lip and craniofacial deformity; 2) repair of abnormally small outer ear (microtia); 3) cleft lip repair.
Kenneth Salyer, MD, of Dallas, a specialist in pediatric plastic surgery, has witnessed many times the additional anguish caused to families by denied insurance coverage. "It is an outrage that families must also have to worry about obtaining insurance coverage for medically necessary procedures during this already stressful time in their lives. Battling with insurance companies for coverage only adds to the tragedy of their situation."
Reasons for denials most often cited by insurance companies are: the procedure is not medically necessary, is cosmetic in nature, or is not needed for functional purposes.
The American Medical Association defines cosmetic and reconstructive surgery as follows, and encourages third-party payers to use these definitions in determining eligible services for coverage under the plans they offer or administer:
Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.
Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.
"The organizations involved are committed to this issue," says Dr. Lynch. "We want to ensure that parents can focus on caring for their child, not hassling with insurance companies for coverage they rightfully deserve."
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The American Society of Plastic and Reconstructive Surgeons represents 97 percent of all physicians certified by the American Board of Plastic Surgery (ABPS). By choosing an ASPRS member plastic surgeon who is certified by ABPS, patients are ensured that the physician has graduated from an accredited medical school and completed at least five years of additional residency, usually three years in general surgery and two years of plastic surgery. To be certified by ABPS, a physician must also practice plastic surgery for two years and pass comprehensive written and oral examinations. Consumers may call the Plastic Surgery Information Service at 1-800-635-0635 or access the ASPRS web site at www.plasticsurgery.org for informational brochures and names of qualified plastic surgeons in their areas.
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