Stakeholders push hard for custom breast forms bill

WASHINGTON – The top priority for supporters of legislation seeking to require Medicare to pay for custom breast forms is to get it re-scored, says Nikki Jensen. 

A previous score by the Congressional Budget Office in December 2020 came in much higher than expected because the CBO scored it as if all women, not just some of them, would choose the pricier custom option. 

“We’re working now with Senator Duckworth’s office, hoping to send a letter to the CBO with several senators signing on in support of re-scoring the bill,” says Jensen, vice president of Essentially Women. “In the last session, in our conversations with most offices, we would fully disclose that we had a CBO score that the CBO acknowledged was wrong, but most offices would tell us to notify them when the bill had been re-scored.” 

Sens. Tammy Duckworth, D-Ill., and Lisa Murkowski, R-Alaska, in October re-introduced The Breast Cancer Patient Equity Act, which would modify the Social Security Act to allow custom forms as an option. The bill is a companion bill to H.R. 4779, introduced in July by Reps. Judy Chu, D-Calif., and Mariannette Miller-Meeks, R-Iowa.  

Since 1999, Medicare has had a code and an allowable (about $3,000) for custom breast forms, but local coverage determinations down code them as "not medically necessary,” even though other custom prostheses, like eyes and ears, are covered. 

“The breast is the only part of the body not covered by Medicare for a prosthetic,” said Jill Robbins, co-owner of The Perfect Match in Camp Hill, Pa. “CMS’s rule saying it’s not medically necessary for women is about as ludicrous as you can get.” 

For those working on the front lines with patients, telling a woman who is undergoing treatment for breast cancer and who can’t afford it a custom breast form, otherwise, that Medicare won’t pay is difficult, they say. 

“I’ve had to do this many, many times,” said Mary Aframe Walsh, owner and founder of The Women’s Image Center in Worcester, Mass. “They are saddened by it, and they feel neglected by their health care plans. When something is made specifically for you, it fits better and is more comfortable.” 

Women’s health providers say they are once again ramping up efforts to get awareness – and sign-ons – for the bills. 

“We do campaigns on our social media with all our followers and direct them to Let her Decide,” said Shellie Graf, president and founder of Elegant Essentials in Medina, Ohio. “I think it’s proven to be beneficial, but I’m happy to do anything if anyone has other suggestions. I can’t believe it’s 2023 and we’re still fighting for this.”