Insurance Coverage for DIEP Flap Procedures

At Texas Breast Center, Dr. Gorman is dedicated to offering breast cancer patients the most cutting-edge, individualized, and targeted breast surgery and breast cancer treatments available. Because of this, she partners with other doctors to offer her patients a team approach to their treatment and recovery. She expertly guides patients through the process of determining the most appropriate cancer treatment options and the most beneficial surgical procedures. But, she is aware that she is not the final stage of the healing journey. Reconstruction after mastectomy for breast cancer is a common medical necessity. As a result, Dr. Gorman has partnered with Dr. Potter to offer breast reconstruction to her patients for more than 15 years.

Dr. Gorman always has her patients in mind and strives to keep them informed of any changes or developments that could potentially affect them during their course of treatment. Recently there has been a change in insurance coding that could affect patients planning to have the DIEP flap method of breast reconstruction, which she would like to make patients aware of.

What is DIEP flap surgery?

DIEP flap surgery is a method of breast reconstruction. DIEP stands for the deep inferior epigastric perforator artery, which runs through the abdomen. DIEP flap surgery involves transferring fat, skin, and blood vessels from the abdominal wall to the chest in order to reconstruct the breast. A DIEP flap is regarded as a muscle-sparing type of flap.

Using microsurgery, the surgeon reconnects the flap’s blood vessels to the patient’s existing blood vessels in the chest. Because no muscle is harvested for the DIEP flap, most women have a shorter recovery time and a reduced chance of losing abdominal muscular strength compared to the TRAM flap procedures.

Not every surgeon is qualified to do DIEP flaps, and the technique is not offered at all hospitals because it necessitates specialized training and knowledge in microsurgery. This is why it is important to find a skilled reconstructive surgeon like Dr. Potter, who has been performing these procedures for over 15 years.

Will health insurance companies cover DIEP flap surgery?

In spite of the fact that the DIEP flap surgery has been covered by the vast majority of commercial health insurance providers since 2007, doctors may soon be unable to bill insurance companies because the procedure will no longer have a unique billing code.

The Centers for Medicare & Medicaid Services (CMS) is a federal agency responsible for enforcing the use of specific billing codes for medical services. These codes are used by doctors to charge a medical insurance company, which may cover all or part of the amount, depending on the policy. There used to be separate ICD-10 codes for DIEP flap breast reconstruction and other perforator flap breast reconstruction surgeries.

The decision to group all breast reconstruction surgeries using flaps under a single code was made by CMS in 2019, and the agency plans to completely phase out the use of individual procedure-specific codes by the end of 2024. As a result, insurance companies will only pay what they would have paid for TRAM flap surgery, an older, less sophisticated, and less common treatment of cancer that is linked to more long-term risks than when a surgeon performs DIEP flap surgery. It’s estimated that the cost of TRAM flap surgery is between 70 and 90 percent less than that of DIEP flap surgery.

At that rate, health care professionals simply cannot afford to offer DIEP flap surgery, so patients are left with two options: pay out of pocket for the procedure (which can cost over $50,000) or settle with less ideal treatment options.

Some health insurance issuers have already stopped covering DIEP flap surgery even before the coding changes take effect next year. Some doctors are now declining to do the procedure altogether even if the patient’s insurance policy still covers it, while others will only do so if their patients can pay the full cost of the operation upfront.

All commercial health insurance policies may discontinue covering DIEP flap surgery between now and next year if CMS’s decision is not reversed soon.

What about the Women’s Health and Cancer Rights Act of 1998 (WHCRA) and the Affordable Care Act?

United States federal law and some state laws guarantee that women can use their health insurance plan to pay for breast reconstruction if they need it. Group health plans and health insurance companies (including HMOs) are obligated to cover all phases of medical care, including breast reconstruction, if they pay for a mastectomy under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). While the law does provide mandatory coverage for mastectomy and breast reconstruction, the regulation does not outline the specific procedures of breast reconstruction that must be covered, making this coding change problematic.

The WHCRA does not apply to some types of health insurance programs, including some self-funded, short-term, government health plans and plans sponsored by religious organizations. Medical assistance programs like Medicare and Medicaid are likewise excluded from the restrictions of the law. They operate by their own set of standards. Medicare covers breast reconstruction using breast prostheses if you had a mastectomy because of breast cancer. Medicaid coverage for breast reconstruction varies by state.

Under the Affordable Care Act, health insurance companies must cover breast cancer treatment and follow-up care. But again, it does not guarantee which specific procedure must be covered.

What can patients do?

Get in touch with your senator and local representative and ask them to lobby CMS to reverse the changes made to the descriptor of CPT code 19364 and restore billing codes S2068 (for DIEP flap surgery), S2066 (for SGAP surgery), and S2067 (for stacked flap surgery). Doing so helps guarantee that all forms of breast reconstruction will be covered by health insurance plans for women who have been diagnosed with breast cancer.

If you have had or are considering DIEP flap reconstruction, you may want to write about your experience and explain the significance of the procedure to you and your breast cancer therapy and how important health insurance coverage is for this surgery.

There are some financial assistance programs for women facing breast cancer that are available for breast cancer treatment that may be able to help with the medical expenses of breast reconstruction if it is not covered by your individual health policy.

A breast cancer diagnosis can be a stressful time, and Dr. Gorman makes it her mission to ease the burden through an advanced, personalized, and targeted approach to treatment. For more information about breast cancer treatment, breast cancer surgery options, and the compassionate care offered by Dr. Gorman at Texas Breast Center, visit the website or call to schedule your consultation.