New Law Requires California Health Care Insurers to Cover Reconstructive Surgery
A new law became effective in California on July 1, 1999, requiring health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease, to do either of the following:
- To improve function.
- To create a normal appearance, to the extent possible.
The statute defines cosmetic surgery as surgery that is performed to alter or reshape normal structures of the body in order to improve appearance.
Read the new California law
The Treatment of Children's Deformity Act (H.R. 49) Summary and Status
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American Medical Association's Resolution 119
States Initiate Legislation to Combat Insurance Coverage Denials for Children's Deformities
The bill would require insurance companies to cover reconstructive surgical procedures for those children with congenital or developmental deformities, diseases or injuries
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Treatment of Children's Deformities Act Introduced in US House of Representatives
WASHINGTON, D.C. -- The Treatment of Children's Deformities Act (H.R. 49) was reintroduced in the U.S. House of Representatives with the support of The American Society of Plastic and Reconstructive Surgeons (ASPRS). The re-introduction of the bill in the 106th Congress, is the result of efforts by ASPRS and groups representing other medical specialties and patients, to highlight the problem of insurance denials for treatment of children's congenital defects. The bill was first introduced near the end of the last congressional session.
This bi-partisan legislation was introduced January 6, 1999, by Representatives Sue Kelly (R-NY), Greg Ganske (R-IA), Ben Gilman (R-NY), Gary Condit (D-CA) and Carolyn Maloney (D-NY).
 "ASPRS is proud to stand with the cosponsors of this bill to fight for the right of children born with an abnormal appearance," said ASPRS President Paul L. Schnur, M.D.
The bill would require insurance companies to cover reconstructive surgical procedures for those children with congenital or developmental deformities, diseases or injuries. Coverage would be required for surgical procedures designed to improve the function of abnormal body structures, or to restore those body structures to a more normal appearance. In addition, a similar bill will likely be introduced in the Senate in the near future.
"We are thrilled that members of the 106th Congress recognize the importance of highlighting this issue. Hopefully, the re-introduction of the bill will result in passage of this much-needed legislation," added Dr. Schnur.
In addition, state legislators have begun to examine this issue. Currently, 14 states have laws that address insurance coverage for children's deformities or craniofacial disorders. For example, California recently passed a law (A.B. 1621) prohibiting HMOs from denying patients reconstructive surgery to correct birth defects or other medical abnormalities. According to an ASPRS survey, 53.5% of surgeons surveyed indicated that they have had at least one pediatric patient in the last two years who has been totally or partially denied coverage, or has had difficulty obtaining approval for insurance coverage for craniofacial and/or congenital defects procedures. Of those patients, 74% had been denied coverage for an initial procedure, and 53% had been denied for subsequent procedures.
The childhood deformities, disfigurements and congenital defects procedures most often denied insurance coverage are associated with: 1) cleft-lip repair; 2) nose reshaping for congenital nasal deformities related to cleft-lip and craniofacial deformity; 3) repair of abnormally small outer ear (microtia).
ASPRS is working with the following organizations to raise awareness of insurance denials for treatment of children's deformities: American Society of Maxillofacial Surgeons, American Cleft Palate-Craniofacial Association, American Society of Craniofacial Surgery, American Association of Pediatric Plastic Surgeons, American Academy of Pediatrics, American Medical Association, American Academy of Child and Adolescent Psychiatry, American Association of Plastic Surgeons, American College of Surgeons, American Pediatric Surgical Association, American Society for Surgery of the Hand.
"This legislation is a necessary step in returning the focus of health care where it should be, on the needs of the patient," said Dr. Schnur.
The Treatment of Children's Deformity Act (H.R. 49)
Summary and Status
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