LBBC issues statement to CMS on coding changes for breast reconstruction

Living Beyond Breast Cancer (LBBC), a national nonprofit organization serving over 600,000 people, strongly recommends that the U.S. Centers for Medicare and Medicaid Services reverse its decision to eliminate individual S billing codes for tissue-based breast reconstruction surgeries. The plan—using one code for all tissue-based reconstructions of widely varying cost—is set to go into effect in late 2024. However, in response, insurance companies have already reduced access to DIEP flap surgery, a critical option for many women. Reversing this decision would restore previous breast reconstruction access to which women are entitled under the Women’s Health and Cancer Rights Act of 1998. It is imperative that CMS use its authority to restore the codes without delay or condition.

At LBBC, our mission is to connect people with trusted, evidence-based content and a community of support. We provide comprehensive information about breast reconstruction options through our heavily trafficked website; key partnerships; and program, outreach, and service materials. We are committed to addressing disparities in breast cancer care, and we have launched numerous initiatives serving the unique needs of different populations.

The CMS coding changes have a disproportionate impact on women of color, younger women, and women in rural communities. Extensive past research suggests Black women are more likely to select tissue-based reconstruction than white women (S. Connors, et al; S. Soni, et al). People with more aggressive cancers whose treatment requires radiation are also more likely to choose tissue-based reconstruction, and those people tend to be younger and non-white.

Because no muscle donor tissue is required, women who undergo the DIEP flap procedure recover more quickly than women having other tissue-based reconstructions, allowing them to resume physical activities. Advances in microsurgery have greatly improved outcomes. As a more complex and longer procedure than older forms of breast reconstruction, DIEP flap surgery is expensive, with some of our community members reporting costs of $50,000 or higher. Since the CMS code change announcement, some health insurers have already greatly reduced coverage for this surgery, and some surgeons are being compensated at a much lower rate that is equivalent to the costs of older forms of tissue reconstruction. LBBC community members have shared chaotic experiences of being denied the DIEP flap option previously covered by their insurers. Now, some women are unable to find a doctor to perform this surgery — or can only get it by paying cash.

CMS sets far-reaching precedents. As a key partner in ensuring patient access, a CMS decision to restore the S codes—without conditions such as tying the S codes to other CPT codes—will set a standard for insurers, surgeons, and the women in their care. LBBC and our community are grateful that CMS is holding hearings and that they are open to listening to the very real, human experiences resulting from this decision.

Women of all backgrounds deserve equal access to all breast reconstruction options. Restoring the S codes would once again empower women to avoid some of the devastating physical, emotional, and financial impacts of breast cancer.

Jean Sachs, MSS, MSLP
CEO
Living Beyond Breast Cancer