Sample Letter for Your Senator and Representative

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Please feel free to copy and paste the letter below as is, or edit as you see fit with your own voice and/or experiences.

You can find your state’s Senator and Representative contact information here.

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Dear [Senator / Representative name here],

As woman and a constituent, I request that you please join the fight to protect breast cancer patients’ rights and access to quality breast cancer treatment under the Women’s Health and Cancer Rights Act (WHCRA) of 1998. Recent changes in medical coding by the Centers for Medicare and Medicaid Services (CMS) are drastically limiting the breast reconstruction options women have available through their insurance plans, potentially making procedures like the DIEP flap, which is the gold standard technique for breast reconstruction, a viable choice only for the very wealthy.

Women diagnosed with breast cancer, or a genetic mutation that predisposes them to the disease, will need to consider mastectomy as one of the countless treatment decisions they face. Several options are available for those who choose to have breast reconstruction, including (i) autologous “flap” reconstruction (using the patient’s own tissue), or (ii) implant-based reconstruction (insertion of a breast implant).

While implants are very frequently used for breast reconstruction, they are associated with device failure, high re-operation rates, Breast Implant Illness (BII), and malignancies such as Anaplastic large-cell lymphoma (ALCL). Having access to breast implant alternatives is therefore desperately needed.

Microsurgical (or “free flap”) reconstruction refers to tissue transplanted from another part of the patient’s body. While there are several types of microsurgical flap procedure, the most commonly performed use the patient’s lower abdominal tissue. The skin and fat below the belly button feels very similar to breast tissue and is therefore the preferred option to replace the tissue removed by the mastectomy.

The traditional technique that transfers the lower abdominal tissue, known as the TRAM (transverse rectus abdominis myocutaneous) flap, sacrifices the patient’s abdominal muscle as part of the procedure. TRAM flap surgery is associated with long hospitalizations, prolonged recovery, decreased abdominal strength, and complications such as hernia formation because it removes all or part of a woman’s core abdominal (rectus abdominis) muscles. Some patients suffer long term disability from removal of their abdominal musculature.

As breast reconstruction techniques have evolved, the DIEP (deep inferior epigastric perforator) flap revolutionized reconstruction by providing a natural, warm, soft breast without permanently damaging the abdominal muscles. Since the DIEP flap preserves abdominal muscle, it is associated with significantly better patient outcomes including shorter hospital stays, faster recovery, and a lower risk of complications compared to the TRAM flap. For these reasons, the DIEP flap is the gold standard for breast reconstruction today. From a patient perspective, even though both the DIEP and TRAM procedures use lower abdominal tissue, we face very different propositions with potentially vastly different outomes.

Until recently, DIEP flap breast reconstruction and other complex microsurgical breast reconstruction procedures (such as GAP flaps and stacked flaps) had unique insurance codes, known as “S-codes”. These are specialized codes that were created to allow US plastic surgeons to bill insurance plans for these complex breast reconstruction procedures that require greater expertise than the older techniques.

In 2019, the CMS combined all microsurgical breast reconstruction procedures together under one code. In January 2021, CMS made the further decision to eliminate the S-codes: sunsetting of codes S2066, S2067 and S2068 has been scheduled for December 31, 2024. This means that plastic surgeons will no longer be able to use S-codes for billing insurance companies for these very complex surgeries. Moving forward, surgeons performing a DIEP flap reconstruction will only be able to bill insurance plans using the same rate as the older, less sophisticated free TRAM flap procedure.

While plastic surgeons will still theoretically be able to offer the DIEP flap and the other modern procedures under the “catch-all” 19364 code, the anticipated sunsetting of the S-codes has already led to some insurance plans slashing physician reimbursement for DIEP flap reconstruction so much, fewer surgeons are now offering the procedure through insurance. This in turn is limiting our access to this gold standard reconstructive option. Multiple commercial health insurers will likely follow suit and as a result, fewer American patients will have access to DIEP flap surgery and other advanced microsurgical breast reconstruction options through their insurance plans. The most likely outcome is that very soon, only the most wealthy of Americans will have access to these advanced types of reconstructive surgery.

One in eight women will be diagnosed with breast cancer in their lifetimes, and there are over 3.8 million women survivors in the U.S. today. The consequences of these coding changes are potentially catastrophic as they will significantly limit our access to the modern, muscle-preserving reconstructive techniques that we have the right to consider through insurance under WHCRA. As outlined above, this is happening already because insurance companies are taking advantage of the recent coding changes at our expense. For this reason, we respectfully request this coding issue is remedied immediately. Additionally, the current language in the WHCRA is dated and does not go far enough to prevent this. The language in WHCRA must therefore be updated and strengthened significantly to ensure insurance companies cannot use breast reconstruction coding changes (recent or future) to their advantage at the cost of patient access. An updated WHCRA must protect full, affordable patient access to all breast reconstruction procedures through insurance, including modern muscle-preserving microsurgical procedures like the DIEP flap, irrespective of the billing code(s) used now or in the future. After all, what good is having rights if we don’t have access?

Thank you for your attention, and support of the breast cancer community.

Sincerely,

[Your name here]

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