JOHN YANG: Health insurance companies are changing the way they reimburse doctors for performing a complicated type of breast reconstruction surgery.

Doctors and patients fear the changes will make the procedure inaccessible to all but the wealthiest.

Eli Rogin's report is part of our ongoing series unequal treatment, looking at inequities in the health care for women.

ELI ROGIN: The surgery is known as DIEP flap reconstruction.

It uses a person's own blood vessels fat and skin to reconstruct the breast.

Older, less complex reconstruction methods use abdominal muscles, but they often lead to complications like hernias, and muscle weakness.

Since 2006, doctors have built insurance companies for DIEP flap reconstruction using a unique four digit code.

But now that code is sunsetting over the next two years.

Instead, DIEP flap surgeries will be built with a different code that also includes those older, less complex procedures, which are also cheaper to perform.

Doctors and patients worry that this will lead to insurance companies only reimbursing the value of the older, less complex procedures and that doctors might not be able to perform DIEP flap surgery unless patients pay out of pocket.

We spoke to some women who have received or are hoping to receive this surgery.

DIANE HEDITSIAN, Diagnosed with Breast Cancer: I'm Diane Heditsian and I'm 68 years old, I was diagnosed with breast cancer and I had three different lumps.

KATE GETZ, Diagnosed with Breast Cancer: My name is Kate Getz and I am 30 years old.

I was diagnosed in January of 2023 with breast cancer.

LATISHIA WHEATON, Diagnosed with Breast Cancer: My name is Latishia Wheaton.

I'm 50 years old.

I was diagnosed with triple negative breast cancer on March 11, 2020.

I had to do like 16 rounds of chemo.

JENNI OSIER, Prophylactic Mastectomy Patient: My name is Jenni Osier and I am 46 years old.

I had a prophylactic mastectomy due to genetic mutation and family history.

I had originally planned to go with implants, but my body rejected the tissue expanders.

So deepest my only option now for reconstruction.

JESSICA HEZKIAH: My name is Jessica Hezekiah.

I am 37 years old.

My surgeon recommended that DIEP flat over having an implant because of radiation having 33 treatments probably would not support the implant.

WAI-CHOO FINCH: My name is Wai-Choo Finch and I'm 65 years old.

It just looked like natural breast so it makes it easier for you to move forward.

LATISHIA WHEATON: I'm just amazed how good of a job that my breasts you cannot really tell I had reconstruction surgery.

DIANE HEDITSIAN: I was extremely happy with the results.

I just felt whole again.

JESSICA HEZKIAH: Going through chemo and going through radiation you don't look at yourself.

You're bystandard you don't know that person because you get put through.

Chemo radiation you become a number in a clinic, but to have your surgeon make subtle changes and have your insurance cover that for you.

Now I look at myself and I'm who I am before I had all my treatments done.

DIANE HEDITSIAN: I see taking away the insurance code for this particular kind of surgery as an access issue.

If we don't win our fight to get this reversed.

It's going to end up that the DIEP flap and other flap surgeries are just not available to underserved women.

LATISHIA WHEATON: We need more people on board about this.

This is very, very important because this is going to change people body images.

KATE GETZ: It is 2023.

We have made surgical advances.

We are doing better and healthcare, you know than we ever have been.

And women should be seeing the benefits of that.

ALI ROGIN: Joining me now is Dr. Elizabeth Potter.

She is a plastic surgeon who specializes in breast reconstruction, and is a co-founder of the Community Breast Reconstruction Alliance, an advocacy group dedicated to preserving access to DIEP flap reconstruction.

And a note some of the women we just heard from are her patients.

Dr. Potter, thank you so much for joining us.

You are one of a relatively small handful of doctors who perform this type of procedure, and to give people a sense of where DIEP flap surgery fits into the broader breast reconstruction landscape.

DIEP flap reconstruction constituted 17 percent of reconstructive surgeries in 2020.

Can you explain what goes into this surgery?

DR. ELISABETH POTTER, Breast Reconstruction Surgeon: DIEP flap surgery is really the culmination of many years of surgical refinement and a technique that we as reconstructive surgeons, used to transfer a woman's own tissue to her chest to create a natural breast.

During a DIEP flap surgery, I remove skin and fat and blood vessels, no muscle from the abdomen area that's similar to the area that might be removed during a tummy tuck procedure.

But instead of discarding that, we are able to carefully connect blood vessels in the chest so that that breast is then living on the chest, we can then mold that into the shape that's most natural for the patient.

And then the patient moves forward with a breast that is there for their lifetime, very different from an implant.

ALI ROGIN: And why would somebody choose this surgery over a breast implant?

ELISABETH POTTER: You know, patient choice is critical here.

So, someone might just prefer to not have a foreign body.

There are a lot of issues that have come up around implant safety over the last several years.

The more we know, the more patients are informed about risks regarding implants.

There's cancers associated with implants and other complications.

There's also the fact that implants are not lifetime devices and have to be maintained and potentially replaced several times over a patient's lifetime.

Importantly, there is a real clinical reason why many women need to have natural tissue reconstruction.

And that's radiation.

So radiation is an important part of the treatment for breast cancer.

And for women who have to have radiation, an implant is a less safe option.

So for women with a more advanced cancer, with a younger age of diagnosis, or a more aggressive type, who might need to have radiation.

This is really the gold standard of reconstruction.

ALI ROGIN: Doctor, access to this kind of surgery is already very limited.

Lots of insurance plans don't cover it.

So how would these coding changes affect the access that already exists?

ALISABETH POTTER: So actually, under the Women's Health and Cancer Rights Act of 1998, access to reconstruction is really should be guaranteed least coverages, although it's difficult to talk about money in cancer, and especially to talk about payments for physicians.

This is about patience.

If we decrease the payment to surgeons, then quietly those procedures go away.

And the woman who finds herself needing to find a surgeon or a procedure will find that it doesn't exist in her community.

ALI ROGIN: And stakeholders like insurance companies and the federal government, they say that this change was always supposed to happen that the unique code that previously was used for the surgery was always meant to be temporary.

And that this change means that it's just a more mainstream surgery and can be identified using one of these existing codes.

How do you respond to that?

ELISABETH POTTER: I think that that's a really important point to make.

This is not the time to be taking this code way.

Patient outcomes weren't considered in removal of this code.

And despite the fact that insurance companies could plan to change codes over time, we weren't allowed to have a discussion about patient impact and the implementation of this change.

So absolutely.

Can we work together to work over time if codes need to be changed or addressed?

Yes, but a drastic change in coverage.

A drastic change in access is what's happening now and that's not OK. ALI ROGIN: So who has the power to change this?

ELISABETH POTTER: The Centers for Medicaid and Medicare have the ability to restore these codes and they honestly have the power to do that pretty quickly.

We're seeing right now that patients are being asked to pay cash for the surgeries and facing decreased access in their communities.

ALI ROGIN: And Dr. Potter there's a much broader conversation have -- being had right now about women's health access who gets to make these decisions is this surgery and the changes to the way it's dealt with administratively?

Is that part of that larger conversation?

ELISABETH POTTER: Absolutely it is.

This effort really highlights so many problems that we're facing in healthcare.

Right now we need for women to have access to care that is best for them from the patient perspective.

To me, that's the most important thing that we're seeing.

We need to pivot away from just the dollars and cents of insurance companies and surgeons, and we need to look at patient outcomes and what patients need.

ALI ROGIN: Dr. Elisabeth Potter, a breast reconstruction specialist and the co-founder of the Community Breast Reconstruction Alliance.

Thank you so much for your time.

ELISABETH POTTER: Thank you, Ali.

JOHN YANG: We asked the Centers for Medicare and Medicaid Services about the change.

Official said phasing in the new code allows more than two years for providers and payers to adjust.

And that will give doctors and insurers ample time to consult with the American Medical Association which administers the code.