[Congressional Record Volume 145, Number 39 (Thursday, March 11, 1999)]
[Senate]
[Page S2576]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mrs. FEINSTEIN:
  S. 585. A bill to require health insurance coverage for certain 
reconstructive surgery; to the Committee on Health, Education, Labor, 
and Pensions.


                   reconstructive surgery act of 1999

 Mrs. FEINSTEIN. Mr. President, today, I am introducing a bill 
to require health insurance plans to cover medically necessary 
reconstructive surgery for congenital defects, developmental 
abnormalities, trauma, infection, tumors, or disease.
  This bill is modeled on a new California law and responds to the 
growing incidence of denials of coverage by insurance, often managed 
care. Despite physicians' judgment that surgery is often medically 
necessary, too many plans are labeling it ``cosmetic surgery.'' The 
American Medical News calls the HMO's response that these surgeries are 
cosmetic as, ``a classic health plan word game. . . .''
  Testifying before the California Assembly Committee on Insurance, Dr. 
Henry Kawamoto put it well. He said:

       It used to be that if you were born with something 
     deforming, or were in an accident and had bad scars, the 
     surgery performed to fix the problem was considered 
     reconstructive surgery. Now, insurers of many kinds are 
     calling it cosmetic surgery and refusing to pay for it.

  The Los Angeles Times reported on July 9, 1997, ``There has been a 
virtual wipeout of coverage to repair the appearance of children whose 
looks are affected by illness, congenital abnormalities or trauma.''
  Similarly, the New York University Physician reported in their spring 
1998 issue:

       Before the advent of managed care, repairing abnormalites 
     was considered reconstructive surgery and insurance companies 
     reimbursed for the medical, hospital and surgical costs of 
     their rehabilitation. But in today's reconfigured medical 
     reimbursement system, many insurance companies and managed 
     care organizations will not pay for reconstruction of facial 
     deformities because it is deemed a ``cosmetic'' and not a 
     ``functional'' repair.

  This bill is endorsed by the March of Dimes, the American Academy of 
Pediatrics, the National Organization for Rare Disorders, the American 
Society of Plastic and Reconstructive Surgeons, the American College of 
Surgeons, the American Association of Pediatric Plastic Surgeons, the 
American Society of Craniofacial Surgery, the American Society of 
Maxillofacial Surgeons, the American Society of Plastic and 
Reconstructive Surgeons and the National Foundation for Facial 
Reconstruction.
  The children who face refusals to pay for surgery are the true 
evidence that this bill is needed.
  Hanna Gremp, a 6-year old from my own state of California, was born 
with a congenital birth defect, called bilateral microtia, the absence 
of an inner ear. Once the first stage of the surgery was complete, the 
Gremp's HMO denied the next surgery for Hanna. They called the other 
surgeries ``cosmetic'' and not medically necessary.
  Michael Hatfield, a 19-year old from Texas, who has gone through 
similar struggles. He was born with a congenital birth defect, that is 
known as a midline facial cleft. The self-insured plan his parents had 
only paid for a small portion of the surgery which reconstructed his 
nose. The HMO also refused to pay any part of the surgery that 
reconstructed his cheekbones and eye sockets. The HMO considered some 
of these surgeries to be ``cosmetic.''
  Cigna Health Care denied coverage for surgery to construct an ear for 
a little California girl born without an ear and only after adverse 
press coverage reversed its position saying that, ``It was determined 
that studies have show some functional improvement following surgery.''
  Qual-Med, another California HMO, denied coverage for reconstructive 
surgery for a little boy without an ear, a condition called microtia, 
and after only many appeals and two years delay, authorized it.
  The bill uses medically-recognized terms to distinguish between 
medically necessary surgery and cosmetic surgery. It defines medically 
necessary reconstructive surgery as surgery ``performed to correct or 
repair abnormal structures of the body caused by congenital defects, 
developmental abnormalities, trauma, infection, tumors, or disease to 
(1) improve functions; or (2) give the patient a normal appearance, to 
the extent possible, in the judgment of the physician performing the 
surgery.'' The bill specifically excludes cosmetic surgery, defined as 
``surgery that is performed to alter or reshape normal structures of 
the body in order to improve appearance.''
  Examples of conditions for which surgery might be medically necessary 
are the following: cleft lips and palates, burns, skull deformities, 
benign tumors, vascular lesions, missing pectoral muscles that cause 
chest deformities, Crouson's syndrome (failure of the mid-face to 
develop normally), and injuries from accidents.
  The American Society of Plastic and Reconstructive Surgeons has 
released a survey on reconstructive surgery, concluding that 53.5 
percent of surgeons surveyed have had pediatric patients who in the 
last two years were denied coverage for reconstructive surgery. Of 
those same surgeons surveyed whose pediatric patients were totally or 
partially denied coverage, 74 percent had patients denied for initial 
procedures and 53 percent denied for subsequent procedures.
  Another reason for this bill is that only 17 out of 50 states have 
state legislation which requires insurance coverage for children's 
deformities and congenital defects. My own state, California, passed 
legislation in 1998 requiring insurance plans to cover medically 
necessary reconstructive surgery, and on September 23, 1998 it was 
signed by former Governor Pete Wilson. This bill was enacted after many 
sad personal stories, and hours of testimony were presented to the 
state legislators.
  This bill is an effort to address yet one more development in the 
health insurance industry that almost daily is creating new hassles 
when people try to get coverage for the plan they pay for every month.
  We need our body parts to function and fortunately modern medicine 
today often make that happen. We can restore, repair and make whole 
parts which by fate, accident, genes, or whatever, do not perform as 
they should. I hope this bill can make that happen.
                                 ______