Written by Jen Uscher | Reviewed by 2 medical advisers
January 20, 2023
An obscure change in medical billing may eliminate health insurance coverage for DIEP flap breast reconstruction surgery. The procedure, which has been covered by most commercial health insurance companies since 2007, is not going to have a unique code anymore, making it impossible for surgeons to bill insurance companies.
Medical procedures are billed using codes administered by the Centers for Medicare & Medicaid Services (CMS), a federal agency. Doctors provide these codes when billing health insurance companies, which may — depending on the plan — cover some or all of the cost. Until recently, DIEP flap breast reconstruction and other perforator flap breast reconstruction surgeries had unique procedure codes.
In 2019, CMS decided to combine all flap breast reconstruction procedures together under one code and to phase out the unique codes for individual flap procedures by December 31, 2024. This means that surgeons performing DIEP flap surgery are only going to be able to bill insurance at the rate for TRAM flap surgery — an older, less advanced, and less common procedure that is associated with more long-term complications. TRAM flap surgery is also about 70% to 90% less expensive to perform than DIEP flap surgery.
Since surgeons cannot afford to perform DIEP flap surgery at that rate, people are going to need to either pay out of pocket for DIEP flap surgery (which can cost more than $50,000) or choose treatment paths that may not be the best for them.
Although the coding changes don’t go into effect until next year, some health insurers have already stopped covering DIEP flap surgery. The changes have also spurred some surgeons to only offer the surgery to patients who can pay the full cost of the procedure in cash and others to stop offering the surgery altogether.
If CMS’s decision is not reversed soon, all commercial health insurers may stop covering DIEP flap surgery between now and next year.
According to the American Society of Plastic Surgeons, more than 137,000 women who have been diagnosed with breast cancer undergo breast reconstruction surgery each year. DIEP flap surgery is an advanced form of breast reconstruction that is preferred by many women because it allows them to use their own transplanted 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 TRAM flap surgery.
Decisions about whether to get breast reconstruction and which type to choose are deeply personal. Most advocates, including Breastcancer.org, and most healthcare professionals agree that women need to be able to choose the type of surgery that’s right for them.
People diagnosed with breast cancer are already struggling with high (and growing) out-of-pocket costs for their care. A 2022 Breastcancer.org survey found that of 1,437 people in the United States who were diagnosed with breast cancer in the past 10 years, 47% said their breast cancer-related out-of-pocket costs were a significant or catastrophic burden.
Access to breast reconstruction through health insurance is actually protected by some state laws and by a federal law. The Women’s Health and Cancer Rights Act of 1998 (WHCRA) requires all group health plans and health insurance companies (including HMOs) 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 been calling for CMS to reverse its decision and reinstate billing code S2068.
Watch the CBS News segment about the coding changes.
Contact your senator and local representative and ask them to encourage CMS to reinstate billing codes S2068 (for DIEP flap surgery), S2066 (for SGAP surgery), and S2067 (for stacked flap surgery) and to undo the changes that were made to the descriptor for CPT code 19364. Doing so helps ensure that women diagnosed with breast cancer continue to have access, through health insurance, to all types of breast reconstruction.
You can find a sample letter and email addresses for your senator and representative on the website of Dr. Elisabeth Potter, a plastic surgeon and advocate on this issue, or on the website of The Center for Restorative Breast Surgery.
If you’ve had or are planning to have DIEP flap reconstruction, consider sharing your personal story, including why the procedure is important to you and for your treatment, in your letter.
This information is provided by Breastcancer.org.