NCCS Joins With Patient Advocates and Health Care Professionals to Call on CMS to Ensure Access to DIEP Flap Breast Reconstruction
WASHINGTON, DC, April 3, 2023 – Advocates for individuals in need of breast reconstruction surgery delivered a letter and petition to the Centers for Medicare and Medicaid Services (CMS) today, urging them to reinstate a procedure code that is essential for access to deep inferior epigastric perforator (DIEP) flap breast reconstruction surgery. More than 4,600 individuals from across the country signed the petition. The letter to CMS was signed by 34 patient advocacy organizations, 12 medical professional societies, and 231 health care professionals, including hospitals, practices, and individual health care providers. Read the letter below or download a PDF here.
Breast reconstruction following a mastectomy can significantly affect a person’s body image, self-esteem, and quality of life. Reconstruction also provides individuals with a choice and some sense of control, allowing them to work with their health care providers to choose the type of breast reconstruction best suited for them. In 2020, 137,000 individuals had breast reconstruction surgery; of those, 25,000 received DIEP flap breast reconstruction.
The Women’s Health and Cancer Rights Act of 1998 provides rights and protections to individuals who want breast reconstruction after a mastectomy. Reconstruction options include flat closure, implant-based reconstruction, or autologous reconstruction using a patient’s own tissue for reconstruction. For many patients, DIEP flap reconstruction is their preference because it avoids the use of a breast implant and has positive outcomes including reduced hospitalization, quicker recovery times, faster return to work, and overall better quality of life than other autologous surgeries. DIEP is also a critically important option for individuals who have received or will need radiation treatment.
In January 2021, CMS announced the sunsetting of code S2068 for DIEP flap breast reconstruction and the use of CPT® code 19364 for autologous flap breast reconstruction procedures. This has led to many downstream effects, where private payers are no longer differentiating between the DIEP flap and transverse rectus abdominis (TRAM) flap surgery, an older, more invasive procedure, which removes all or part of an individual’s core muscles and may result in long-term disability, long hospitalization, decreased strength, and hernia formation.
The coding change led to drastic lowering of reimbursement for DIEP surgeries. The lack of adequate reimbursement may lead surgeons to forgo offering the surgery, given the costs to provide it. Alternatively, surgeons may only offer the surgery if patients can pay cash, exacerbating health disparities. Since the CMS announcement, patients report not being able to find surgeons in their network and/or local area who offer DIEP surgeries at the reimbursement rate offered by their insurance, whether Medicare, Medicaid, or private insurance.
Brenda in Loveland, Colorado, shared her challenge finding an experienced surgeon in Colorado who will accept Medicaid. She said, “The right to reconstruction should never be stripped from us as breast cancer patients, previvors or survivors. My only option is a flap surgery because I received so much radiation after my direct to implant reconstruction failed post double mastectomy. I’m now left with no breast on my left side and a big implant on my right side. In order to be made whole again, I need a DIEP flap, as an implant is not an option due to radiation.”
“In 1998, Congress passed the Women’s Health and Cancer Rights Act (WHCRA) to ensure individuals diagnosed with breast cancer would have access to reconstruction. WHCRA is a short law, written so that it would not become outdated as the medicine and available procedures improved. However, these code changes run contrary to the intent behind WHCRA and are causing real barriers to care for individuals seeking access to medically appropriate breast reconstruction after a cancer diagnosis,” said Shelley Fuld Nasso, CEO of the National Coalition for Cancer Survivorship.
“The surgeries now included in 19364 are not equal. We have come so far in breast reconstruction, and it’s important that patients continue to benefit from that progress. TRAM flap surgery is easier on the doctor and harder on the patient. A DIEP flap is harder on the doctor and easier on the patient. With the development of modern techniques, the burden has been assumed by the surgeon and removed from the patient,” Dr. Elisabeth Potter, a microsurgeon in practice in Austin, Texas, who cares for patients with Medicare, Medicaid, Tricare, and commercial payers.
“Our organizations, and the organizations and individuals who signed the letter and petition to CMS, believe that all individuals in need of breast reconstruction deserve access to DIEP flap reconstruction, if that is their preference. The first step in restoring access is to reinstate the codes that allowed adequate reimbursement for this important procedure,” said Lisa Schlager, Vice President of Public Policy for Facing Our Risk of Cancer Empowered (FORCE).
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Group Letter to CMS
April 3, 2023
The Honorable Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
200 Independence Avenue SW Washington, DC 20201
Dear Administrator Brooks-LaSure:
The undersigned organizations, advocates for individuals in need of breast reconstruction who seek access to quality care, write today to urge reversal of the elimination of a procedure code for deep inferior epigastric perforator (DIEP) flap breast reconstruction surgery. We ask the Centers for Medicare & Medicaid Services (CMS) to reinstate code S2068, as its elimination has already threatened access to DIEP flap surgery. If action is not taken, we fear that DIEP flap surgery, a reconstruction surgery preferred by many individuals, will no longer be an option for any except those who can pay out-of-pocket for the surgery. Removing code S2068 also has the potential to exacerbate disparities in access to quality breast cancer care.
Some of us were involved in passage of the Women’s Health and Cancer Rights Act of 1998, and all of us have been engaged in the years since to make the protections of that law a reality for patients who choose breast reconstruction in connection with a mastectomy. A key element of our efforts has been providing these patients with access to information about breast reconstruction options so that they can make informed decisions about the best option for them, if they wish to undergo reconstruction.
Patient education regarding breast reconstruction includes a review of options, including implant-based reconstruction or autologous reconstruction, using a patient’s own tissue for reconstruction. Individuals undergoing mastectomy have benefited significantly from improvements in surgical techniques, including the development of the DIEP flap reconstruction technique. For many, DIEP flap reconstruction is their preference because it may avoid the use of a breast implant and has positive patient outcomes including reduced hospitalization, quicker recovery times, faster return to work, and overall better quality of life than with other autologous options. The DIEP is preferred by many over transverse rectus abdominis (TRAM) flap surgery, a traditional form of autologous reconstruction surgery. TRAM flap, which removes all or part of an individual’s core muscles, may result in long-term disability, long hospitalization, decreased strength, and hernia formation. DIEP is also a critically important option for individuals seeking reconstruction who either have received or will need radiation treatment.
CMS reports that the discontinuation of the three S codes related to breast reconstruction – including S2068 for DIEP flap or superficial inferior epigastric artery (SIEA) flap – was requested by the Blue Cross and Blue Shield Association. This request was considered during the 2021 HCPCS Coding Cycle, including at a public meeting. CMS further reports that it has decided to eliminate three S codes (S2066, S2067, and S 2068) on December 31, 2024. Instead, CPT® code 19364 will be used for autologous flap breast reconstruction procedures.
In a response to Members of Congress who requested reconsideration of the elimination of code S2068, CMS stressed that it was providing more than a year transition period for providers and payers to make adjustments in coverage policies and claims processing systems and to make any needed payment adjustments. We can report on how that transition period has been proceeding to date. Payers are moving quickly to utilize CPT® code 19364 and effectively reduce payment and essentially eliminate coverage for DIEP flap. Surgeons report that payers are not engaging with them to make needed payment adjustments for 19364.
The patients we represent report that DIEP flap is increasingly not an option for them. Many are simply no longer offered the option of DIEP flap surgery. Those who are provided the option or who learn about it and seek to have the surgery find that access may depend on their ability to self-pay. If these patients receive prior authorization for DIEP flap surgery, their hospital may not accept the rate of payment for code 19364.
As advocates for individuals in need of breast reconstruction, we engage in policy activities to improve patient access to quality breast cancer care. However, we have not to date been actively engaged in development, revision, and implementation of payment codes. As a result, we were not at the HCPCS meeting where breast reconstruction S codes were discussed. If we had been, we would have explained the importance of DIEP flap as a reconstruction surgery option and the need for code S2068 to guarantee coverage and payment. Now that we have experienced a crash course in coding for breast reconstruction surgery, we raise our voices to urge a reversal of the decision to eliminate code S2068.
Retention of code S2068 is an action that would be consistent with the patient-centric goals of CMS. Retention of the code would prevent exacerbation in disparities in access to breast reconstruction surgery. Retention of the code would honor the Cancer Moonshot goals of helping “patients and families have the best experience possible while living with and surviving cancer, and to improve patient outcomes.”
We look forward to hearing from you soon, and we stand by to meet with you at your convenience to share our perspective on coding and payment for breast reconstruction surgery.
Sincerely,
Patient Advocacy Organizations
Annie Appleseed Project
Breast Cancer Prevention Partners
Breast Implant Safety Alliance (BISA)
Breastcancer.org
Breastoration
Cactus Cancer Society
Cancer Support Community
CancerCare
Community Breast Reconstruction Alliance
DIEP Flap Support Group
DiepCFoundation.org
Family Reach
FORCE: Facing Our Risk of Cancer Empowered
Going Beyond the Pink
Lazarex Cancer Foundation
Living Beyond Breast Cancer
Midlothian Moms
National Coalition for Cancer Survivorship
Not Putting on a Shirt
NothingPink
Patient Empowerment Network
SHARE Cancer Support
Sharsheret
Sisters Network, Inc.
Stand Tall AFC
Susan G. Komen
The Breasties
The Young Breast Cancer Project
Tigerlily Foundation
Triage Cancer
Virginia Breast Cancer Foundation
Young Survival Coalition
Health Care Professionals
American Academy of Physician Associates
American Society of Breast Surgeons Foundation
Association of Community Cancer Centers
Association of Physician Assistants in Oncology
Association of Physician Associates in Obstetrics and Gynecology
Association of Plastic Surgery PAs
California Society of Plastic Surgeons
Community Oncology Alliance
Northwest Society of Plastic Surgeons
Texas Medical Association
Washington Society of Plastic Surgeons
Advanced Reconstructive Care, LLC
Aesthetic Center for Plastic Surgery
Austin Breast Imaging
Austin Face and Body
Austin Plastic & Reconstructive Surgery
Avraham Plastic Surgery
BASS Medical Group
Breast Body Beauty Plastic & Reconstructive Surgery
Breast Cancer High Risk Program, SUNY Upstate Medical University
Cardinal Plastic Surgery
Center for Restorative Breast Surgery
ChristianaCare
Comprehensive Breast Center of Arizona
Cusimano Plastic Surgery
Division of Plastic & Reconstructive Surgery, LSU, New Orleans
Elizabeth Institute
Epic Care Plastic Surgery
Ford Plastic & Reconstructive Surgery
Greenwich Hospital
Guste Plastic Surgery
Hanemann Plastic Surgery
Harbor-UCLA Medical Center
Hartford Healthcare
Mass General Brigham
Mercy Medical Center
Methodist Hospital
Mission Health
Moffitt Cancer Center
Monmouth Medical Center
Northwest Breast Center, Spokane, WA
NYBRA Plastic Surgery
Pink Lotus Breast Center
Plastic & Reconstructive Surgery at Mercy
Plastic Surgery Clinic, Denver, CO
Plastic Surgery Northwest
PRMA Plastic Surgery
Providence Cancer Institute
Radiology Partners
Regional Plastic Surgery Center
Revalla Plastic Surgery
Revitalize Plastic Surgery
Rose Imaging Specialists
Rush University Division of Plastic Surgery
RVA Plastic Surgery
Samra Plastic Surgery
San Francisco Plastic Surgery
Select LTC Pharmacy
Snyder Plastic Surgery
South Georgia Medical Center
Southwest Breast and Aesthetics
St. Catherine of Siena Hospital
St. David’s HealthCare
St. David’s Medical Center
Taylor Plastic Surgery
Texas Breast Specialists
Texas Oncology PA
The Center for Natural Breast Reconstruction
The Institute for Advanced Breast Reconstruction
The Plastic & Reconstructive Surgery Group
Tulane University Medical Center Division of Plastic Surgery
UK HealthCare
University of Florida
University of Southern California
University of Washington Center for Reconstructive Surgery
V Plastic Surgery
Vanderbilt University Medical Center
Wildflower Breast Center, PLLC
Women’s Cancer and Wellness Institute
Yates Institute of Plastic Surgery
Zampell Plastic Surgery
A. Marilyn Leitch, MD
Aaron Pelletier, MD
Abby Culver, MD
Adam Perry, MD
Aimee Mackey, MD
Aislinn Vaughan, MD
Alexander Au, MD
Alfred Culliford IV, MD
Allison DiPasquale, MD
Amy Eastman, MD
Amy S. Nordmann, MD
Andrea L. Pusic, MD, MHS, FACS, FRCSC
Andrei Odobescu, MD, PhD
Andrew Zhang, MD
Anjali R. Thawani, MD
Anne Peled, MD
Anu Shultz, MD
Archana Ganaraj, MD
Armen Kasabian, MD
Ashley Gordon, MD
Bardia Amirlak, MD
Beverly A. Zavaleta, MD
Boris Goldman, MD
Bouchra Younes, MD
Bryan Correa, MD
Caroline Coombs-Skiles, MD, FACS
Charles E. Frank, MD, MBA
Christine A. Stiles, MD
Christopher Trahan, MD, FACS
Claudine Egol, MD
Colleen O’Kelly Priddy, MD, FACS
Crystal A. Champion, PT, DPT, CLT-ALM
Daniel Liu, MD
Danielle DeLuca-Pytell, MD, FACS
Danielle Dumestre, MD
David Kurlander, MD
Deana Shenaq, MD
Derek Fletcher, MD
Diana Hook, MD
Dr. Garza Plastic Surgery
Dr. Robyn Roth
Elaina Chen, MD
Elisabeth Potter, MD, PLLC
Elizabeth Feldman, MD
Elizabeth OConnor, MD
Elizabeth Sieczka, MD
Emily Van Kouwenberg, MD
Emily Williams, MD
Erika Giovanniello, DNP CRNA
Erin Atkinson, PhD
Erin Carroll, PA-C
Erin Fleener, MD
Erin Woods, RN, BSN
Eva Notis, DO
Evan W. Beale, MD, PA
Frank J. DellaCroce, MD, FACS
Frederick J. Duffy, Jr., MD
George Kokosis, MD
Grace Ma, MD, FACS
Hala Sabry, MD
Haley Bunting, MD
Igor Burko, MD
Jamie E. Terry, MD, FACS
Jana Wise, RN
Jenni Harris, DO
Jennifer Bonafiglia, APN
Jennifer Hawasli, MD
Jennifer S. Kargel, MD
Jennifer Sasaki, MD
Jessica Erdmann-Sager, MD, FACS
Jessica Monas, MD
John Hyun, MD
Johnson C. Lee, MD
Joshua J. Goldman, MD
Joshua Lemmon, MD, PLLC
Joyce Aycock, MD
Juan Jose Gilbert Fernandez, MD, FACS
Jules Andrew Walters III, MD
Julie Vasile, MD, FACS
Katarzyna Kania, MD
Kathryn A Wagner, MD, FACS
Katrina P.E. Birdwell, MD, FACS
Keith Hood, MD
Kelly Hewitt, MD
Kory Imbrescia, DO
Kristen L. Fernandez, MD
Lauren Mitchell, RN
Lauren Shikowitz-Behr, MD
Lavinia K. Chong, MD, FACS
Lisa Walker, MD
Lori Adelson, MD
Lynn D. Canavan, MD
Marian Bonner, MD
Marian Yvette Williams-Brown, MD
Marilyn Ng, MD
Mark Smith, MD
Mary Oleksiak, MSW
Matthew Carty, MD
Megan Fracol, MD
Meghan Hansen, MD
Melanie Pickering, DO
Melissa Chardos Brinn, MD, FAAP
Melissa Kaptanian, MD, FACS
Melissa Kinney, MD
Melissa Knight, BSN, RN, CNOR
Merisa Piper, MD
Michael Newman, MD
Michelle Fillion, MD
Mohammad Shuja Shafqat, MD
Neil Tanna, MD
Nicholas T. Haddock, MD
Olatomide Familusi, MD
Olumayowa Abiodun, MD
Oren Lerman, MD
Page Plastic Surgery PC
Parin Patel, MD
Patricia Clark, MD, FACS, FSSO
Paymon Rahgozar, MD, QME
Peter Henderson, MD, MBA, FACS
Pooja Sharma, MD
Rachel E. Kaczynski, DO
Rachel Shirley, DO, FACS
Rachel Wooldridge, MD
Radbeh Torabi, MD
Raman Mahabir, MD, FRCSC, FACS
Randall Feingold, MD
Raulee Morello, MD
Rebecca Wiatrek, MD
Reena Vashi, MD
Ricardo Meade, MD
Richard Agag, MD
Richard Ha, MD
Rita Martinez, RN
Roberta Gartside, MD
Ron Israeli, MD
Rukmini S. Rednam, MD
Ryan A. Gruner, MD, FACS
Sarah B. Younger, MD
Sarah Poore, PT, DPT
Sarah Snell, MD
Sean Boutros, MD, FACS
Shareef Jandali, MD
Shayne Taylor, MD
SJ Plastic Surgery
Steve Henry, MD
Suma Maddox, MD
Sumeet S. Teotia, MD
Suraiya Contractor, RN, BSN
Tamara Kemp, MD
Teralyn Carter, MD
Tiffany B. Grunwald, MD, FACS
Travis Boyd, MD
Tuoc Dao, MD
Victor Moon, MD
Vinod V. Pathy, MD, FACS
Vivian Mai-Tran, MD
Wess Cohen, MD
Wojciech Dec, MD
Yi Chuang, MD
Zoe M. MacIsaac, MD, PLC
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