Dutch health insurers give surgeons authority over breast reconstruction approvals

Dutch health insurers have decided that plastic surgeons will now have full authority to decide on breast reconstruction surgeries for breast cancer patients, eliminating the need for prior insurer approval. This decision follows reports by NOS exposing serious issues with reimbursement denials for these procedures.

Previously, women had to obtain approval from insurers before undergoing corrective breast reconstruction surgeries following initial mastectomies. These secondary operations address pain, contour irregularities, or other complications after the first reconstruction. About one in three such requests were denied by insurers, causing distress and delays for many patients.

Joyce Bosman-Kuijntjes, 39, faced repeated refusals from her insurer. She had her breasts removed preventively five years ago due to high cancer risk. Two years ago, her teardrop-shaped implant began to rotate, causing both pain and visible deformity. The insurer rejected her surgery request, judging the problem insufficiently serious.

“It feels so unjust. I was consumed by it day and night,” Bosman-Kuijntjes told NOS. “I did this for my own health. Even the insurer benefits if I reduce my cancer risk. Then complications occur, and they refuse to help. Insurers focus too much on cosmetics because it concerns breasts; they think it’s about making things prettier.” She eventually received coverage for the corrective surgery but is again fighting a denied claim for fixing a dent in her breast.

Petra Wormser, director at the Dutch health insurers’ association, stated prior approval from insurers will no longer be required. “We want women with breast cancer to get proper care quickly and clearly,” Wormser told NOS. From now on, plastic surgeons and patients will decide together if further surgery is necessary in private consultations. This surgeon’s decision will suffice for insurers to approve coverage.

However, Wormser emphasized that the current strict reimbursement criteria applying exclusively to breast reconstructions after cancer will remain. These criteria define which breast areas and deformity sizes qualify for coverage and must still be applied by surgeons.

Only breast reconstruction surgeries after cancer face stringent conditions, unlike other cancers. For example, dents in areas that can be covered by clothing (‘non-functional areas’) must be at least 5 centimeters in diameter and 2 centimeters deep to qualify. In ‘functional areas’ like the cleavage, a 2-centimeter diameter and depth suffice. Legal experts have criticized these rules as discriminatory against women.

Edin Hajder of the Dutch Association for Plastic Surgery (NVPC) said the change could help 300 to 400 additional women annually receive reconstructive surgery, supplementing the current 600 to 700 surgeries done each year. “The strict criteria lead to denials from insurers. Now the doctor decides if the criteria are met.”

Wormser defended the insurers, saying, “We do not think insurers are too strict, but the process could be improved for this group.”

Hajder expects a surge of women whose previous surgeries were denied to revisit their surgeons. “This is a breakthrough for breast cancer patients, especially as photos of breasts will no longer need to be sent to insurers. For patients, this is a clear gain.”

Insurers plan to monitor the new policy to “prevent unjustified increases” and will consult with plastic surgeons about potential consequences. Wormser assured patients will never face unexpected costs if surgeons incorrectly apply the criteria. The NVPC stresses the urgent need to abolish the strict reimbursement rules entirely. “This must change as soon as possible.”