The American Association of Breast Care Professionals (AABCP) strives to
mandate Medicare to offer the option of custom breast prostheses to all
post-mastectomy patients. Currently, these prostheses are down-coded to an
off-the-shelf option that does not always meet patient expectations.
The bill would require Medicare to pay for custom breast prostheses as
prescribed, explained Rhonda Turner, PhD, JD (BOCPO, CFm), president of AABCP
and O&P Business News Practitioner Advisory Council member.
“While there is an L code for custom breast prostheses, and there
is an allowable, they are down-coded in the local coverage determination (LCD)
policy to what they call the least costly alternative,” she said.
“Basically what they do is, they take a custom form and down-code it to a
standard silicon breast form and see no difference in that.”
But to Turner, and women around the country affected by this
legislation, the difference is clear.
“Obviously the silicon forms are premanufactured forms,” she
said. “There are many women who are able to be fit — and happily fit
— with something that is premanufactured but there are many cases where
they can not.”
This is especially prevalent in the older populations where more radical
surgeries have been performed before newer surgical technologies were
available.
“It has an unusually discriminatory effect on the Medicare
population by down-coding this sort of thing,” Turner told O&P
Business News. “Many women, if they can’t get something that
is appropriate or effective for them, they go with nothing at all which has its
own physiological consequences.”
In late April, the U.S. Senate received a new bill for consideration.
S3255, also known as the Custom Fabricated Prosthesis Act 2010, was introduced
by Sen. Blanche Lincoln (D-AR) and cosponsored by Sen. Olympia Snowe (R-Maine)
and Kirsten Gillibrand (D-N.Y.).
In late May, the companion bill, HR5447, was introduced in the House of
Representatives with the help of Rep. Mike Ross (D-AR).
So far, reception to the bill has been sympathetic.
“Many lawmakers are aghast when they find out that this device is
not customized,” Turner said explaining that many physicians and lawmakers
were operating under the assumption that, in all instances, this was a custom
device. “They are somewhat taken aback and they listen a little bit more
intently.”
Turner stresses that custom breast prostheses are not appropriate for
everyone; however, this Act aims to make sure it is an option offered to all
patients.
“I don’t think we’ve come across any significant
pushback,” Turner said. “There’s an ongoing dialogue and we are
cautiously optimistic that we might see some sort of a resolution this year.
With the election coming in the fall, we’re hopeful we will see some
movement before then. I think it’s a good time for this type of
legislation. It’s appropriate legislation. It’s needed legislation
and it doesn’t add to the overall cost.” — by Jennifer
Hoydicz
As a certified mastectomy fitter and one who is constantly seeing the
“latest” surgeries, I am not sure how to react or comment on the
possibility of Medicare offering custom forms at an actual custom price. My
hesitancy is not because there aren’t women who could benefit from a
custom form due to the type of surgery that they had but more to the issue of
how to determine what is an appropriate allowable for something that is custom.
I am not familiar with the cost for a custom leg or arm but I would think that
each patient has to be reviewed on an individual basis and I am not sure
whether Medicare has that capability in this instance. Also if the allowable is
preset, what does the patient do if her custom form costs twice as much? Will
it come out of her pocket or does the prosthetist absorb the cost? Would these
custom forms be produced by a certified prosthetist from materials that they
use for other types of prostheses? If that is the case, what about the bras
that each women would wear to hold the prosthesis in place? There are so many
styles to choose from and not every woman can wear the same style of bra to fit
with their natural breast. Would the prosthetist limit their inventory? If they
do, then even a custom form will not match if the natural remaining breast is
misfit in a bra.
I definitely agree with Ms. Turner that custom forms should have a
higher upgrade, especially knowing that not all pre-manufactured forms fit
perfectly on every woman and that there are instances where a custom form could
fit better. Along with that, I also believe that the Medicare organization has
done a disservice to women by not supporting other options for women who are
difficult to fit. However, I would like to see some of the questions above
answered first before I judge as to whether this legislation actually meets the
needs of mastectomees.
— Judi Simon, CMF
President, Nearly Me
Technologies
