Doctors urge coverage of children's surgery

Physicians see a proposed bill as a way to stop health plan denials of procedures to correct children's anomalies, while insurers call it another expensive mandate.

By Susan J. Landers, amednews staff. April 17, 2000.

Washington -- Two days before Dallas reconstructive plastic surgeon Kenneth Salyer, MD, was to operate on 12-year-old Brenna Nay, her family's insurer denied the coverage.

Brenna has Hajdu-Cheney syndrome, a rare connective tissue disorder. Her family took out a loan to pay for the surgery rather than disappoint their daughter who now encounters ridicule at school and the unkind stares of strangers because of her abnormal facial structure, said her mother.

Dr. Salyer, the Nays and others told their stories at a news conference held to build support for legislation that would prohibit insurers from denying coverage of reconstructive surgery for children born with deformations.

A survey conducted by the American Society of Plastic and Reconstructive Surgeons found that more than half, or 53.5%, of 703 members queried said their pediatric patients had been denied insurance coverage or had experienced obstacles in obtaining approval for treatment of craniofacial and/or congenital anomalies.

Approximately 7% of American children are born with deformations and congenital anomalies such as cleft lips, cleft palates, skin lesions, malformations of the ear and even severe craniofacial deformities, according to the Coalition for Coverage of Children's Deformities, which sponsored the media event. The coalition includes the AMA and 14 medical specialty groups.

AMA Trustee Susan Hershberg Adelman, MD, a pediatric surgeon in a Detroit inner-city neighborhood, told the news conference that insurers sometimes authorize only one surgery when several are necessary.

AMA policy calls for coverage of children's anomalies that the physician considers "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."

Although most insurers will cover reconstructive surgery for children born with anomalies, they do not cover standard cosmetic surgery. Contracts requiring such coverage, however, can be written by employers, said a spokesman for the Health Insurance Assn. of America.

Calling for more

But the legislation's sponsors argue that insurance companies' policies don't go far enough. Their legislation calls for insurers to cover treatments for children up to age 21 conducted to improve function of deformed body parts or to create "normal appearance." The bills would not require plans to cover cosmetic surgery performed to reshape normal body structures to improve appearance or self-esteem.

"Children shouldn't be forced to live to the end of their lives with birth defects that can be corrected," said Rep. Sue Kelly (R, N.Y.), a chief sponsor of the Treatment of Children's Deformities Act.

A companion bill is sponsored by Sens. John McCain (R, Ariz.), whose daughter was born with a cleft lip and cleft palate, and Olympia Snowe (R, Maine). The House measure is also being championed by Rep. Greg Ganske, MD (R, Iowa), a plastic surgeon.

The insurance association opposes the legislative mandate, contending that it would drive up the cost of insurance and add to the growing number of Americans currently unable to afford health insurance.

McCain noted that passage of a patients' rights law, now being debated in Congress, would go a long way toward alleviating the problems of the children targeted for help in his bill. He said the need for patients' rights legislation under the managed care-dominated health system surfaced at all the town hall meetings he held during his now-ended presidential bid.

"If the Republicans understand the mood of the country, they will act and act positively" to pass an effective law, he said.