Breast prostheses could get coverage boost

Wednesday, April 28, 2010

WASHINGTON - In what's described by industry stakeholders as a "win-win," a bill that would require Medicare to pay for custom breast forms was introduced April 22.

"We're very excited about this bill," said Rhonda Turner, president of the American Association of Breast Care Professionals, which worked on the legislation. "There is no rhyme or reason why these are not being paid for."

Medicare already has a code--and an allowable--for custom breast forms, but local coverage determinations (LCDs) down code them as "not medically necessary." That means the custom forms get paid for at the non-custom price--a big difference, said Turner. Custom forms cost about $3,000 while non-custom forms go for $350 to $400, she said.

"We are asking Medicare to pay for (these products) the way they should be paid for," said Turner. "Upon appeal, these forms do occasionally get paid for, but, because of the cost, most (physicians) won't even prescribe a custom form."

That's a problem for women who can't use an off-the-shelf product, such as in cases where the patient has had failed reconstructive surgery or extensive scarring from treatment.

"There are just clinical situations where it doesn't work any other way," said Turner. "The custom form is the true restoration of symmetry."

The Custom Fabricated Breast Prosthesis Act of 2010, S. 3255, is sponsored by Sens. Blanche Lincoln, D-Ark., and Olympia Snowe, R-Maine. Turner said she's optimistic that it can pass as a standalone bill, but said she wasn't adverse to attaching it to an appropriate piece of legislation.