Bill would require Medicare to pay for custom breast forms

Tuesday, June 28, 2011

WASHINGTON - A bill that seeks to get custom breast forms paid for under Medicare was reintroduced June 16.

"Medicare covers custom prosthetics for every other body part except the breast," said Rhonda Turner, executive director of the American Association of Breast Care Professionals (AABCP). "There's a level of inequity there that we haven't figured out."

Medicare already has a code and an allowable for custom breast forms, but local coverage determinations (LCDs) down code them as "not medically necessary."

But, when appealed, Medicare has usually reversed its decision.

"Through appeal, we have been able to (prove) medical need and get the device paid for," said Turner.

With the cost of a custom form around $3,000 compared to $450 for an off-the-shelf product, many women will go without if Medicare doesn't pay, said Turner. That's especially troublesome because not all breast cancer survivors are candidates for reconstruction, or they may be unable to use an off-the shelf form.

"Not everybody can be accommodated in a medically appropriate manner by an off-the-shelf product," said Turner. "There are some conditions, body parts or surgery types that require a little more customization."

The Department of Veterans Affairs, many state Medicaid programs and many private insurers pay for custom forms, Turner said.

The Breast Cancer Patient Equity Act of 2011, S. 1217 and H.R. 2233, was introduced by Sen. Olympia Snowe, R-Maine, and Rep. Mike Ross, D-Ark. It is similar to legislation introduced in 2010. Turner is "cautiously optimistic" this time around.

"Last year was such a difficult year legislatively for so many different industries," she said. "One thing in our favor is that we are not adding a new code or expenditure per se. We feel that people are willing to listen."