Current Policy Priority Successful Effort

Coverage of DIEP Flap and Other Autologous Breast Reconstruction Preserved

August 21, 2023 - Today, the Centers for Medicare and Medicaid Services (CMS) announced it will keep the billing codes for flap breast reconstruction surgeries. This means every woman will have access to advanced breast reconstruction options like DIEP and GAP flap. The decision was in response to a coordinated effort by multiple stakeholders including patients, advocacy organizations, medical professionals, lawmakers and others. Our voices collectively came together, and CMS listened!

Background

In an effort to streamline billing, the Centers for Medicare and Medicaid Services (CMS) announced that the insurance codes used for procedures like DIEP flap breast reconstruction will expire on December 31, 2024. This medical billing change could significantly limit health insurance coverage for certain types of advanced tissue-based breast reconstruction.

On June 1, 2023, CMS held a public hearing regarding concerns about retirement of the DIEP flap and GAP flap breast reconstruction insurance codes. FORCE staff testified asking that the billing codes be retained until at least 2028 to allow the breast cancer community time to identify and institute a long-term solution.

On April 3, FORCE helped spearhead a letter to the Administrator of CMS, urging reinstatement of the procedure code for DIEP flap breast reconstruction surgery. FORCE also joined stakeholders in a letter to the CEOs of the country’s largest commercial health insurers, expressing concerns with recent coverage policy changes decreasing access to certain types of breast reconstruction.

Breast reconstruction following a mastectomy can significantly affect a person’s body image, self-esteem, and quality of life. Reconstruction also gives individuals a choice and sense of control, allowing them to work with their healthcare providers to choose the type of breast reconstruction best suited for them.

Deep inferior epigastric perforator (DIEP) flap surgery is an advanced form of autologous breast reconstruction that allows an individual to use their own transplanted body tissue instead of an implant; it doesn’t involve moving or cutting muscle, and it has a faster recovery time and a lower risk of long-term complications than some other types of flap surgery.

Although the coding change doesn’t go into effect until next year, many commercial health insurers already announced plans to discontinue coverage of these advanced breast reconstruction procedures. Plastic surgeon professional societies and advocacy groups quickly mobilized to temporarily halt the coverage denials.

The Women’s Health and Cancer Rights Act (WHCRA) requires most health plans that pay for mastectomy to also cover all stages of breast reconstruction. However, the law doesn’t specify the types of breast reconstruction surgeries that must be covered, leaving this coding change in a legal gray area. Members of Congress, including Senator Amy Klobuchar and Congresswoman Debbie Wasserman Schultz (both breast cancer survivors), are among those who have urged CMS to reverse its decision and reinstate the billing codes.

FORCE was heavily involved in this effort and will continue representing the interests of our community should future breast reconstruction coverage challenges arise.