S 1217 112th
amend title XVIII of the Social Security Act to provide coverage for custom fabricated
breast prostheses following a mastectomy.IN THE SENATE
OF THE UNITED STATES
June 16, 2011
SNOWE (for herself, Mr. KERRY, Mr. INOUYE, Mr. AKAKA, and Mr. BEGICH) introduced
the following bill; which was read twice and referred to the Committee on Finance
To amend title XVIII of the Social
Security Act to provide coverage for custom fabricated breast prostheses following
Be it enacted by the Senate and House
of Representatives of the United States of America in Congress assembled,
1. SHORT TITLE; FINDINGS.
(a) Short Title- This Act may be cited
as the `Breast Cancer Patient Equity Act'.
(b) Findings- 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
(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.
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
(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
(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.
(a) In General- 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) Conforming Amendment- Section 1862(a)(7)
of such Act (42 U.S.C. 1395y(a)(7)) is amended by striking `1861(s)(8)' and inserting
(c) Effective Date- The amendments made by this
section shall apply to items and services furnished on or after the date of enactment
of this Act.