[Congressional Record Volume 147, Number 37 (Tuesday, March 20, 2001)]
[Senate]
[Pages S2589-S2591]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mrs. FEINSTEIN:
  S. 576. A bill to require health insurance coverage for certain 
reconstructive surgery; to the Committee on Health, Education, Labor, 
and Pensions.
  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 California law and responds to reports that 
insurance plans are denying coverage for reconstructive surgery that 
doctors say is medically necessary. Too many plans are too quick to 
label it ``cosmetic surgery.'' The American Medical News has called the 
HMOs stance, ``a classic health plan word game. . . .''
  Dr. Henry Kawamoto, testifying before the California Assembly 
Committee on Insurance stated:

       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.

  Many doctors have told me that before the heavy penetration of 
managed care, repairing a person's abnormalities was considered 
reconstructive surgery and insurance companies reimbursed for the 
medical, hospital, and surgical costs. But today, many insurance 
companies and managed care organizations will not pay for 
reconstruction of many deformities because they deem them to be 
``cosmetic'' and not a ``functional'' repair.
  This bill is endorsed by the March of Dimes, Easter Seals, the 
American Academy of Pediatrics, the National Organization for Rare 
Disorders, the American College of Surgeons, the American Society of 
Plastic and Reconstructive Surgeons, the American Association of 
Pediatric Plastic Surgeons and the American Society of Maxillofacial 
Surgeons.
  The children who face refusals to pay for surgery are the true 
evidence that this bill is needed. Here are some of the examples that 
were brought to the California legislature:

[[Page S2591]]

  Hanna Gremp, a 6-year old from 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, 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 one and only after adverse press 
coverage reversed its position saying that, ``It was determined that 
studies have shown some functional improvement following surgery.''
  Qual-Med, another California HMO, initially denied coverage for 
reconstructive surgery for a little boy who also had microtia, 
authorizing it only after many appeals and two years delay.
  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.
  This bill is an effort to address the arbitrariness of insurance 
plans that create hassles and question physicians' judgments when 
people try to get coverage under the plan they pay premiums for every 
month.
  We need our body parts to function and, fortunately, modern medicine 
today can 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.
                                 ______