DIEP Flap Insurance Coverage at Risk: Urgent Advocacy Issue

The time to act is now to protect our reconstruction options after breast cancer.  DIEP flap reconstruction, a modern way to rebuild our breast after breast cancer using our tissues while preserving our core muscles, is in danger.  No, it isn’t going away because surgeons aren’t doing it.  It is in danger because of a medical billing (CMS coding) change.

It is time to raise our voices.  Whether you are a breast cancer patient or not, taking action is quick, easy, and can make a difference.

This post will be in two sections- section one will give some background on the topic and share some ways you can take action.  Section two will focus on what to do if you would like a DIEP flap or are in the reconstruction process right now.

Section One: Background and How to Take Action

WHCRA and Our Access to Breast Reconstruction

Before 1998, breast reconstruction after cancer wasn’t considered an essential part of breast cancer treatment.  That all changed with the passage of WHCRA- the Women’s Health and Cancer Rights Act in the United States. 

This act provides protection to patients who have breast reconstruction after a mastectomy.

Specifically, coverage must be provided for the following:

• All stages of reconstruction on the mastectomy breast
• Surgery and reconstruction of the other breast for symmetry
• Prostheses and treatment for any complications (during any part of the mastectomy process), including lymphedema

There are different ways this act applies to health plans, and I won’t go into deep detail here.  You can read more here.

While our access to breast reconstruction is guaranteed, the specific types of reconstruction we may have access to are not specified in this act.

Progress in Breast Reconstruction

There are many different ways our breasts can be reconstructed after a mastectomy.  One is with implants.  Another is using our tissue, fat, and/or muscle to reconstruct a breast. These are called Flap surgeries, and there are many different types.

One of the most popular Flap surgeries at this time is the DIEP Flap surgery. This complex surgery requires surgeons to do extra training so they are skilled in the microsurgical techniques necessary for a successful reconstruction. 

DIEP flap reconstruction takes fat, skin, and blood vessels from the lower abdomen and relocates them to the breast area.  No muscles are cut, which allows the patient to retain her core strength. This is unlike TRAM flap surgeries– which use muscles as well.  

So What Has Changed?

The Center for Medicare and Medicare Services has decided to unify all flap reconstruction surgeries under one master code and eliminate the specific code for DIEP flap.  This means it will be impossible for surgeons to bill health insurance for DIEP surgery.

If surgeons can’t bill insurance for the surgery- then who do you think will pay the price?

Us.

Yes, that’s right.

Unless we have $50,000 sitting around to reconstruct our breasts, we will no longer have the option for this surgery.

Insurance companies are already denying coverage for DIEP.

Potential Ramifications of This Change

What other reconstruction options will go away if we don’t take action now?

Will they stop covering flap rearrangement during a lumpectomy?  Will we no longer have the option to have reconstruction after a mastectomy?  It isn’t hard to think that this is the next step.

It is one thing to talk about this in theory, but what if you are in treatment right now? Letters to your senator will not solve your immediate issues. 

Section Two: What to do if You Want DIEP or Are in the Reconstruction Process

First- a little disclaimer- I’m not an insurance coding specialist, so please take all your questions directly to your medical insurance.  This is only to be considered general advice on the topic.  For more info- see my legalese here.

Medical insurance is complicated enough without needing to double and triple-check our coverage.  But this is where we are right now, especially since these coding changes are in process and insurance companies are changing their policies as I write.

Action Plan

If you are considering a DIEP flap or are in the reconstruction process right now, I recommend doing the following things to clarify and understand your coverage.

1. Start with the surgeon’s office.  Ask the surgeon which CPT codes he will be billing your insurance.  These are 5-digit codes that are directly linked to insurance reimbursement. There may be more than one code.  Ask for all of them. If the surgeon doesn’t know, ask to talk to the medical biller for the office.
2. Ask if they will be seeking pre-authorization for your surgeries.  If they have already done so, request copies of those authorizations for your record.
3. Ask the medical billing team what your patient responsibility for the surgery will be.
4. Take all this information, especially the 5-digit codes, and call your insurance.
5. Verify your coverage for all of the CPT codes.  Ask your insurance if pre-authorization is required for any of those.
6. Ask what your patient responsibility is for this procedure.
7. Ask what your rights are as a patient if coverage changes while you are in the middle of reconstruction.
8. Write down the information or ask for a copy.  Take down the name of the representative you talked to and note the time and date of your call.
9. After you have had the surgery, watch carefully for any bills.  Take these bills and compare them to your explanation of benefits from your insurance company.  These should line up with what you expected before the surgery.
10. If you receive a bill you aren’t expecting, contact your insurance company.  They can provide you with explanations and also connect you with resources that might be able to negotiate on your behalf.

This type of work is difficult to do, especially as we are walking through the emotional swirl of breast cancer.  I set aside time during my diagnosis process to deal with the admin aspect of breast cancer and make these phone calls.  It wasn’t fun, but it did help me have confidence about my coverage during treatment.

I hope that this coding change is quickly reversed.  But change can only happen when we raise our voices together.

Advocating Together

So, what can we do?

We can write our legislators, share our stories, and advocate for options.

The links below give more information about these changes and have pre-written sample letters available to make writing your legislators easy.

Please take a few moments to reach out.  It is up to all of us to make sure we maintain our reconstruction options after breast cancer.

Breast cancer is hard enough already.  We need more choices, not fewer.

Advocacy Links:

About the Code Change: https://www.breastcancer.org/news/diep-flap-surgery-cms-code-change

Take Action: https://www.drpotter.com/advocacy/

More ways to take action: https://www.breastcenter.com/urge-your-leaders/

Additional letters: https://www.feelforyourlife.com/flap

Clarity about the coding changes and their impacts: https://prma-enhance.com/breast-reconstruction-blog/will-this-simple-coding-change-kill-access-to-diep-flap-breast-reconstruction/

More information about DIEP and reconstruction options: https://www.diepcfoundation.org/