1.
(a)This Act may be cited
as the Breast Cancer Patient Equity
Act
.
(b)Congress
finds the following:
(1)There are
currently 2,500,000 women in the United States living with breast cancer, many
of whom suffer from unreconstructed breast loss.
(2)In 2010, an
estimated 207,090 women were diagnosed with invasive breast cancer that
required surgery, with many having to undergo surgical breast removal.
(3)Annually, there
are more than 130,000 women in the United States who undergo mastectomies, a
surgical removal of the breast.
(4)The number of
breast amputations in the United States is projected to increase due to the
rising incidence of breast cancer and the growing elderly population.
(5)A
woman suffering from the loss of her breast may not be a candidate for surgical
breast reconstruction or may choose not to undergo additional surgery if there
were a viable, less costly, less invasive option available.
(6)The results of
breast reconstruction surgery can vary and, as with any surgical procedure,
there are inherent risks associated with such surgery. Additionally,
reconstruction of the breast using implants can impose increased risks and
costs due to the eventual need for implant replacement surgery.
(7)The number of
women choosing to undergo surgical breast reconstruction continues to increase,
as many women lack the viable option of custom fabricated prosthetic breasts to
restore the lost breast.
(8)Both older women
and minority women are less likely to be offered or undergo surgical breast
reconstruction and are disproportionately disadvantaged by a lack of access to
the option of custom fabricated prosthetic breasts.
(9)Currently, the
Medicare program provides coverage and reimbursement for custom fabricated
prostheses for any body part, with the exception of breasts, that has been
lost.
(10)Following passage
of the Women's Health and Cancer Rights Act of 1998 (Public Law 105–277; 42
U.S.C. 201 note), many private insurers and group health plans began to provide
coverage for custom fabricated breast prostheses as an alternative to surgical
breast reconstruction.
(11)While the
Medicare program recognizes custom fabricated breast prostheses as a discrete
device and valid treatment option, having assigned a billing code for such
option under the Healthcare Common Procedure Coding System (HCPCS)
and setting a maximum allowable fee, Medicare does not provide reimbursement
and denies claims as ‘not medically necessary’. Medicare does provide
reimbursement, however, for more costly surgical breast reconstruction.
(12)Due to the fact
that the Medicare program does not provide reimbursement for custom fabricated
breast prostheses, many private insurance companies have also begun to limit
their reimbursement for them.
(13)The Department
of Veterans Affairs does provide the option of a custom fabricated prosthetic
breast for women post-mastectomy.
(14)Providing
coverage for custom fabricated prosthetic breast devices and components will
not increase the incidence of breast amputations.
2.
(a)Section 1861(s)(8) of
the Social Security Act (42 U.S.C.
1395x(s)(8)) is amended—
(1)by adding and
after the
semicolon at the end;
(2)by inserting (A)
after
(8)
; and
(3)by inserting after
subparagraph (A) the following new subparagraph:
(B)custom fabricated breast prostheses
following surgical removal of the breast, including replacement of such
prostheses;
.
(b)Section 1862(a)(7) of such Act (42 U.S.C. 1395y(a)(7))
is amended by striking 1861(s)(8)
and inserting
1861(s)(8)(A)
.
(c)The amendments made by this section shall apply to items and
services furnished on or after the date of enactment of this Act.