Changes to a specialized insurance code (known as the “S-Code”) are limiting patient access to highly specialized, “natural” breast reconstruction procedures that use the patient’s own tissue instead of implants. Access to DIEP flap surgery, which is the gold standard muscle-preserving procedure, is being hit particularly hard.
Breast implants and are the most commonly used method of breast reconstruction in the US. However, implants can leak or rupture, have high re-operation rates, and can also be associated with Breast Implant Illness (BII), and malignancies such as Anaplastic large-cell lymphoma (ALCL). Ensuring patients have access to breast implant alternatives under insurance is therefore a priority.
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 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, following a request from a major insurance company, CMS made the further decision to eliminate the S-codes. These codes will sunset on December 31, 2024. After that date, surgeons performing DIEP flap surgery will only be able to bill insurance plans using the same code as the older, less sophisticated free TRAM flap.
Despite the S-codes still being in effect until December 31, 2024, a handful of insurance plans have already declared their intent to stop covering DIEP flap surgery under the S-code. Some have temporarily back-tracked due to patient backlash, but insurance companies will likely continue down this path once the codes sunset. As a result, it is possible that only the most wealthy of American patients will have access to these modern surgeries after December 2024.
Thankfully, following immense public pressure and feedback, CMS recently announced they are holding a hearing on June 1, 2023 to reconsider these breast reconstruction coding changes. You can see the full CMS meeting agenda for the June 1, 2023 hearing here.
CMS wants to hear about the obstacles patients are facing in getting access to DIEP flap surgery. Please sign up to attend the hearing and share your comments – use this link to register (enter agenda item #1).
You can also email your thoughts and any experiences you’re comfortable in sharing ahead of the meeting to HCPCS@cms.hhs.gov. Please speak from the heart and explain why you feel it is crucial to preserve full patient access through insurance, and the right to choose any reconstructive option after a mastectomy, including advanced muscle-preserving procedures like the DIEP flap. Please feel free to personalize and edit this letter, or borrow snippets as you see fit.
Every voice helps. Please take this opportunity to have your voice heard!