Patient access to DIEP flap surgery and other modern breast reconstruction procedures is under threat in the US because of changes in insurance coding by the Centers for Medicare & Medicaid Services (CMS).
Women diagnosed with breast cancer, or a genetic mutation that predisposes them to the disease, will need to consider mastectomy as one of their countless treatment decisions. Several options are available for those who choose to have breast reconstruction. These include (i) autologous “flap” reconstruction (using the patient’s own tissue), or (ii) implant-based reconstruction (insertion of a breast implant).
Microsurgical (or “free flap”) reconstruction refers to tissue transplanted from another part of the patient’s own body. The skin and fat below the belly button feels very similar to breast tissue. It is therefore the preferred option to replace the tissue removed by a mastectomy.
The traditional technique that uses the lower abdominal tissue is known as the TRAM (transverse rectus abdominis myocutaneous) flap. This sacrifices the patient’s abdominal muscle as part of the procedure. Since it removes all or part of a woman’s core abdominal (rectus abdominis) muscles, TRAM flap surgery can be associated with long hospitalizations, prolonged recovery, decreased abdominal strength, and a higher risk of abdominal complications such as hernia formation.
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 shorter hospital stays, faster recovery, and a lower risk of complications compared to the TRAM flap. For these reasons, the DIEP flap is considered today’s gold standard in breast reconstruction.
The DIEP flap and other advanced, modern microsurgical breast reconstruction procedures (like the GAP flap, stacked flaps) currently have unique billing codes in the US, known as “S-codes”. These specialized billing codes allow US plastic surgeons to bill insurance plans for these more complex procedures that require additional training and expertise.
In 2019, CMS combined all microsurgical breast reconstruction procedures together under one code (CPT 19364). In January 2021, CMS made the further decision to eliminate the S-codes. Sunsetting of these codes is scheduled for December 31, 2024. After that date, surgeons performing a DIEP flap reconstruction will only be able to bill insurance plans using the same code as the older, less spohisticated free TRAM flap technique.
Despite the S-codes still being in effect until December 31, 2024, some insurance plans are already declaring their intent to stop covering DIEP flap surgery under the S-code. Between now and next year, multiple commercial health insurers will likely follow suit. As a result, fewer patients will have access to DIEP flap surgery and other advanced microsurgical breast reconstruction options through insurance. In fact, this situation is already playing out. Very soon, it is possible that only the most wealthy of American patients will have access to these modern surgeries. If we don’t act now, this situation will become the new status quo in the US.
According to Breast Advocate founder and PRMA Plastic Surgery President, Dr. Chrysopoulo, “CMS coding changes alone do not make surgeries defunct. What we have here is a patient access issue.”
The Women’s Health Cancer Rights Act (WHCRA) of 1998, states that insurance coverage must be provided for your breast reconstruction, symmetry procedures of the remaining breast, and treatment of complications like lymphedema, if you are receiving benefits in connection with a mastectomy and choose to have breast reconstruction.
Unfortunately, the current language in the WHCRA is dated and does not go far enough in protecting patient access to modern reconstruction techniques like the DIEP flap.
“Ultimately, what good are breast reconstruction rights if patients don’t have access to modern surgical techniques?”, says Dr. Chrysopoulo. “Now is the time for patients and surgeons to come together and push for WHCRA to be updated. This is the only way to ensure patients continue to have access to all their post-mastectomy reconstructive options long-term, regardless of what happens on the coding front, which is extremely political.”
We strongly urge patients to use their voices! Please contact your state’s Senator or Representative immediately: request this coding issue is remedied, and WHCRA is updated to ensure insurance companies provide full patient access to all modern breast reconstruction options, regardless of the billing codes used now and in the future.
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