“You have breast cancer,” are words you never want to hear. But every two minutes, a woman in the United States is told this. By the end of 2023, an estimated 297,790 women will receive this diagnosis, making it one of the most common cancers in American women, according to the Breast Cancer Research Foundation. Each of these individuals deserves a treatment plan that is tailored to their needs.
Chemotherapy and radiation are common treatments, as is surgery, such as a lumpectomy or a mastectomy, which is typically followed by reconstruction. There are two options for rebuilding: implants (either saline or silicone) or the use of autologous tissue (meaning your own living tissue). For the latter, the gold standard is called a deep inferior epigastric perforator, or DIEP flap, which transfers a person’s tissue from the abdomen (without cutting through muscle) to re-create their breasts. “The goal is to replace human anatomy with something that is as much like the original as possible,” says Joshua Levine, MD, a board-certified microsurgeon in New York City.
In 2021, however, the status of this gold standard in breast-reconstruction surgery became unclear. The Centers for Medicare and Medicaid Services (CMS) bundled many flap reconstructions covered by insurance under one CPT code, which is used for administrative purposes like processing insurance claims. This change, which was set to take effect in 2024, would limit how health care providers could bill for the surgery. Providers would be able to bill insurance only at the rate for less expensive surgeries.
“The DIEP code was developed in order for a doctor to say, ‘I’m doing a better surgery for my patient,’ for a patient to say, ‘I want that better surgery,’ and for an insurance company to have to pay for the work of doing that surgery,” Dr. Elisabeth Potter, a board-certified plastic surgeon in Austin, told The Peak, a media platform started by The Breasties. Dr. Potter, the Community Breast Reconstruction Alliance (CBRA), The Breasties, and the breast cancer community advocated together to protect patient access to covered flap reconstruction. Because of their efforts, the decision to change the coding was reversed in August 2023.
During this time of uncertainty, patients were preparing for scheduled DIEP flap procedures without knowing whether the cost of their reconstruction — sometimes upwards of $50,000 without insurance — would even be covered.