The S-Code Insurance Code And The Impact On DIEP Flap Breast Reconstruction

The S-Code Insurance Code And The Impact On DIEP Flap Breast Reconstruction

The Women’s Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that provides protections for patients who choose to have breast reconstruction following mastectomy.  The law states that all surgery related to breast cancer must be covered by insurance plans, including the breast reconstruction chosen by the patient in consultation with her reconstructive surgeon.  It also stipulates that it is unlawful for insurance companies to alter reimbursement in any way that would limit patients’ access to care.

Current efforts to “sunset”, i.e. end, the S-Code will do exactly that, and patients are already being negatively impacted.

There are different types of breast reconstruction available to women who face breast cancer and mastectomy.  The gold standard is called the Perforator Flap.  The most common Perforator Flap is the DIEP.  This is an operation that uses the patient’s own abdominal skin and fat to reconstruct a living, natural breast.  The living tissue is harvested with highly sophisticated micro-surgical techniques so that the underlying muscle is preserved.

Perforator flaps are performed by highly trained specialists with extensive micro-surgical experience.  Most plastic surgeons do not offer these top-of-the-line operations because they require substantial extra experience and training, and because they require more time and care before, during and after surgery.  Many plastic surgeons who offer these operations chose to focus their practices solely on these highly advanced procedures due to the tremendous time and dedication required to perform them successfully.

Perforator Flap procedures for breast reconstruction have been designated by their own code by the insurance companies.  The “S-Code” reflects the procedure’s higher level of sophistication, and allows the operating surgeon to bill and be reimbursed accordingly.

Since insurance companies have begun to eliminate (“sunset”) the S-Code, fewer plastic surgeons are offering DIEPs and other Perforator Flaps to breast cancer patients.

Patients are being forced to choose inferior options, like breast implants or muscle destroying operations.  Many patients are not offered Perforator Flaps at all, or they are told that they “are not a candidate,” when they actually are.

This is particularly tragic for patients who have had breast reconstructive operations that have failed.  Implant failure is very common and can result in major morbidity like chronic pain and infections and Breast Implant Illness (BII). Implants have also been associated with an increased risk of lymphoma (BIA-ALCL).  Perforator Flaps can permanently solve these problems, and may be the only hope for these patients.  With a decline in these operations’ availability, these patients are being left with no options at all.

The elimination of the S-Code will continue to disincentivize plastic surgeons from offering the best operations, and patients will more and more be subjected to inferior and even inappropriate reconstructive options.  This takes away a women’s right to choose, and it is illegal under the WHCRA.

Sharsheret is a national not for profit cancer support and education organization and does not provide any medical advice or perform any medical procedures. Sharsheret does not endorse or promote any specific medication, treatment, product, or service, and makes no guarantees regarding the effectiveness of the product discussed herein. The information provided herein is not a substitute for professional medical advice or treatment. You should always seek the advice of your physician or other qualified health provider.