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Challenges to breast reconstruction equity: How insurance billing code changes affect your choices

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The Women’s Health and Cancer Rights Act of 1998 entitles individuals who have undergone a mastectomy due to breast cancer to breast reconstruction, ensuring that financial barriers do not limit access to essential care. This legislation promotes equitable healthcare by mandating insurance coverage for reconstruction. Individuals diagnosed with breast cancer have several reconstruction options available to them, each with varying associated risks, monetary costs, and insurance coverage considerations. The diverse range of procedures allows patients to select the one that best aligns with their personal needs, preferences, and financial situation. Unfortunately due to an insurance billing code update one important option may soon be unattainable for many.

Context and Background:
Although the majority of patients choose implant-based surgeries, the deep inferior epigastric perforator (DIEP) flap reconstruction surgery is the best choice for many patients and an important option for the community. For example, a DIEP flap method is often a preferred option for women who have radiation therapy after breast surgery, for several reasons. Radiation can damage the skin and tissues in the breast area, making it more difficult to reconstruct the breast using an implant. In some cases, radiation can also cause scarring or tissue contraction, which can further complicate the use of an implant. In contrast, a DIEP flap reconstruction surgery uses the patient’s own tissue from the lower abdomen to create a new breast, avoiding the need for an implant and reducing the risk of complications related to radiation damage.

Surgeries for breast reconstruction have specific codes for billing that are managed by the Centers for Medicare & Medicaid Services (CMS). CMS is responsible for developing and enforcing regulations related to healthcare providers, insurance companies, and other entities involved in the healthcare industry. The agency announced that in December 2024 changes to the coding system will retire the DIEP-specific code and group the DIEP flap breast reconstruction surgery with other less advanced flap reconstruction surgeries.

Urgency and Impact:
This insurance coding change is problematic because it treats all types of natural tissue reconstruction as equal, despite the fact that they are very different from both the patient’s perspective and the time and expertise required of the surgeon. The CMS changed the coding system in response to insurance company requests to pay the same rate for all types of breast reconstruction. The price of a DIEP flap surgery without insurance coverage is $50,000 or more making it cost-prohibitive to all but the wealthy.

Solutions and Calls to Action:
Thankfully, the breast cancer community is already rallying against this change, and the Community Breast Reconstruction Alliance, an advocacy group, pushing to protect access for all patients has been created to organize and lead the effort. According to the organization, these are the best ways to get involved.

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