We have multiple patients being told be Aetna insurance specifically that their bilateral simple mastectomy with free nipple grafting gender-affirming top surgery HAS to be coded as CPT 19318-50 (breast reduction) in order to receive pre-approval. However, according to everything I have known, colleagues, my understanding of the CPT code book descriptions of the procedure, Google AI and Chat GPT, the codes are 19303-50 and 19350-50. And this is in patients that are otherwise stated to have coverage for top surgery. They even have a policy statement about it: https://www.aetna.com/cpb/medical/data/600_699/0615.html. Regardless of anyone's feelings about gender affirmation surgery and insurance coverage for it, this seems like a clear case of an insurance company dictating care to a provider, which seems ethically wrong. Am I alone in thinking that?
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Kristopher Day MD
Pacific Sound Plastic Surgery
Bellevue WA
425-818-8991
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