Read Jean Sachs’ blog “Stop new limits on breast reconstruction” at LBBC.org.
WASHINGTON, DC, April 3, 2023 – Advocates for individuals in need of breast reconstruction surgery delivered a letter and petition to the Centers for Medicare and Medicaid Services (CMS) today, urging them to reinstate a procedure code that is essential for access to deep inferior epigastric perforator (DIEP) flap breast reconstruction surgery. More than 4,600 individuals from across the country signed the petition. The letter to CMS was signed by 34 patient advocacy organizations, 12 medical professional societies, and 231 health care professionals, including hospitals, practices, and individual health care providers.
Breast reconstruction following a mastectomy can significantly affect a person’s body image, self-esteem, and quality of life. Reconstruction also provides individuals with a choice and some sense of control, allowing them to work with their health care providers to choose the type of breast reconstruction best suited for them. In 2020, 137,000 individuals had breast reconstruction surgery; of those, 25,000 received DIEP flap breast reconstruction.
The Women’s Health and Cancer Rights Act of 1998 provides rights and protections to individuals who want breast reconstruction after a mastectomy. Reconstruction options include flat closure, implant-based reconstruction, or autologous reconstruction using a patient’s own tissue for reconstruction. For many patients, DIEP flap reconstruction is their preference because it avoids the use of a breast implant and has positive outcomes including reduced hospitalization, quicker recovery times, faster return to work, and overall better quality of life than other autologous surgeries. DIEP is also a critically important option for individuals who have received or will need radiation treatment.
In January 2021, CMS announced the sunsetting of code S2068 for DIEP flap breast reconstruction and the use of CPT® code 19364 for autologous flap breast reconstruction procedures. This has led to many downstream effects, where private payers are no longer differentiating between the DIEP flap and transverse rectus abdominis (TRAM) flap surgery, an older, more invasive procedure, which removes all or part of an individual’s core muscles and may result in long-term disability, long hospitalization, decreased strength, and hernia formation.
The coding change led to drastic lowering of reimbursement for DIEP surgeries. The lack of adequate reimbursement may lead surgeons to forgo offering the surgery, given the costs to provide it. Alternatively, surgeons may only offer the surgery if patients can pay cash, exacerbating health disparities. Since the CMS announcement, patients report not being able to find surgeons in their network and/or local area who offer DIEP surgeries at the reimbursement rate offered by their insurance, whether Medicare, Medicaid, or private insurance.
Brenda in Loveland, Colorado, shared her challenge finding an experienced surgeon in Colorado who will accept Medicaid. She said, “The right to reconstruction should never be stripped from us as breast cancer patients, previvors or survivors. My only option is a flap surgery because I received so much radiation after my direct to implant reconstruction failed post double mastectomy. I’m now left with no breast on my left side and a big implant on my right side. In order to be made whole again, I need a DIEP flap, as an implant is not an option due to radiation.”
“In 1998, Congress passed the Women’s Health and Cancer Rights Act (WHCRA) to ensure individuals diagnosed with breast cancer would have access to reconstruction. WHCRA is a short law, written so that it would not become outdated as the medicine and available procedures improved. However, these code changes run contrary to the intent behind WHCRA and are causing real barriers to care for individuals seeking access to medically appropriate breast reconstruction after a cancer diagnosis,” said Shelley Fuld Nasso, CEO of the National Coalition for Cancer Survivorship.
“The surgeries now included in 19364 are not equal. We have come so far in breast reconstruction, and it’s important that patients continue to benefit from that progress. TRAM flap surgery is easier on the doctor and harder on the patient. A DIEP flap is harder on the doctor and easier on the patient. With the development of modern techniques, the burden has been assumed by the surgeon and removed from the patient,” Dr. Elisabeth Potter, a microsurgeon in practice in Austin, Texas, who cares for patients with Medicare, Medicaid, Tricare, and commercial payers.
“Our organizations, and the organizations and individuals who signed the letter and petition to CMS, believe that all individuals in need of breast reconstruction deserve access to DIEP flap reconstruction, if that is their preference. The first step in restoring access is to reinstate the codes that allowed adequate reimbursement for this important procedure,” said Lisa Schlager, Vice President of Public Policy for Facing Our Risk of Cancer Empowered (FORCE).
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Community Breast Reconstruction Alliance
FORCE: Facing Our Risk of Cancer Empowered
National Coalition for Cancer Survivorship
