On June 16, Sen. Olympia Snowe (R-Maine) in the Senate and Rep. Mike
Ross (D-Arkansas) in the House of Representatives introduced the Breast Cancer
Patient Equity Act of 2011. The bill, which has 10 cosponsors, seeks to
“amend title XVIII of the Social Security Act to provide coverage for
custom-fabricated prostheses following a mastectomy.” As of press time,
both bills, S. 1217 and H.R. 2233, were in committee. A similar bill introduced
last year failed to make it out of committee.
Custom-fabricated
breast prostheses are the only custom prostheses not covered
by Medicare, and in turn, many private insurance companies have limited their
reimbursements for these prostheses, according to the bill.
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“A number of people are working diligently to get this in the minds
of enough people to bring this up for a vote,” Rhonda Turner, president of
the American Association of Breast Care Professionals (AABCP) and O&P
Business News practitioner advisory council member, told O&P
Business News. “Right now we are at the grassroots level trying to
garner awareness in the House and Senate. We are cautiously optimistic.”
Need for custom breast forms
Congress found that in 2010, an estimated 207,090 women were diagnosed
with invasive breast cancer that required surgery, with many having to undergo
breast removal. According to the bill, a woman suffering from the loss of her
breast may not be a candidate for surgical breast reconstruction because of
additional health concerns or because she may choose not to undergo additional
surgery if there was a less expensive option available. Reconstruction of the
breast using implants can lead to increased risks and costs. Older women and
minority women are less likely to undergo surgery but also lack access to the
option of custom-fabricated prosthetic breasts, Congress found.
“The custom breast form is just like a custom prosthesis,”
Turner said. “You would have to either cast it or use a computer- assisted
design/manufacturing scanning system and go through the whole process. And then
there is a fitting. Custom breast forms are usually used in cases where you can
not do anything else. That is probably why there is not awareness for the need.
You only need it when nothing else works. But when nothing else works, it is
all you have left.”
According to Turner, women who suffer from severely damaged skin or
obesity, for example, may not fit into off-the-shelf prefabricated breast
prostheses.
Turner found herself talking to a plastic surgeon about a patient who
had extensive scarring from surgery. Off-the-shelf prefabricated forms would
not fit the patient, so Turner asked the plastic surgeon for permission to
approach the patient about a custom breast form. The surgeon told Turner that
he incorrectly thought the prefabricated breast form was a custom breast form.
According to Turner, the breast prostheses are predominantly prefabricated.
“We are seeing an increasing number of these situations in the
Medicare population,” Turner said. “Most forms come premanufactured,
and there are plenty of sizes, shapes and colors. They fit a good number of the
population. I do not think people are even aware that custom breast forms exist
or that they are really needed. I think there is a true lack of awareness for
custom breast forms.”
Extra costs may hinder use
Medicare already has an Lcode, also known as an allowable, for
custom-fabricated breast prostheses. However, they were downcoded to “not
medically necessary” by local coverage determinations (LCDs). Because of
the LCD language, custom forms are paid at the noncustom price. According to
Turner, there is a substantial cost difference — nearly 10-fold —
between off-the-shelf breast forms and custom breast forms. Because of the
price, physicians may hesitate to prescribe the more expensive custom breast
form.
“There has been a bit of ambiguity as to whether or not Medicare
agrees with its own statement on coverage,” Turner said. “At AABCP,
we believe that prosthetics, by their very definition, are custom devices. The
intention of this bill is to require Medicare to pay for custom breast forms.
It is a benefit that is already there. All commercial insurers and Medicaid pay
for custom breast forms. Ultimately this bill is necessary because the women of
the Medicare population are older and have more chronic diseases. They need
this option.” — by Anthony Calabro
For more information:
Library of Congress. H.R. 2233 – Breast Cancer Patient Equity
Act of 2011. Available at:
http://thomas.loc.gov/cgi-bin/query/z?c112:H.R.2233.IH.
Accessed: July 20, 2011.
Disclosure: Turner has no relevant
financial disclosures.
