Hastings Leads Letter Urging CMS to Ensure Full Post-Mastectomy Medicare & Medicaid Coverage for Breast Cancer Patients

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Washington, D.C., October 19, 2019 | comments

Representative Alcee L. Hastings (D-FL) along with Representatives Debbie Wasserman Schultz (D-FL) and Jackie Walorski (R-IN) led the following letter to Seema Verma, Administrator of the Centers for Medicare and Medicaid Services (CMS), urging that CMS work with states and update its own National Coverage Determination (NCD) to more closely align Medicare and Medicaid coverage guidelines with the Women's Health and Cancer Rights Act of 1998 (WHCRA) to ensure full coverage of post-mastectomy breast reconstruction procedures. Nipple-areolar complex (NAC) tattooing is the necessary final stage of the post-mastectomy breast reconstruction procedure, and should be covered for breast cancer patients who choose to undergo it. (Please find below and attached a copy of the letter):

October 18, 2019

The Honorable Seema Verma
Administrator, Centers for Medicare and Medicaid Services
U.S. Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244

Dear Administrator Verma:

As Members of Congress, we are requesting the Centers for Medicare and Medicaid Services (CMS) review Medicare and Medicaid’s coverage of post-mastectomy breast reconstruction nipple-areolar tattooing. With surgical and clinical advancements in breast cancer reconstruction, the number of women pursuing breast reconstruction has trended upward. Post-mastectomy breast reconstruction is now universally recognized as a gold standard component of comprehensive breast cancer treatment. We want to work with you to ensure that patients covered by Medicare are able to access nipple-areolar tattooing.

Women that are interested in breast reconstruction usually have three options. Selection of an option is dependent on the extent of a patient’s disease, reconstructive goals, and quality of tissue available for reconstruction. The final stage of reconstruction is the nipple-areolar complex, fully restoring the breast to a natural, symmetric appearance that would otherwise be incomplete. This is achieved by a combination of tattooing with or without the addition of a surgical procedure to create a nipple. Tattooing alone is at times the only option for nipple-areolar reconstruction in patients that may have damaged tissue due to radiation therapy or simply want to avoid an additional surgical procedure.

Despite the fact that the Women's Health and Cancer Rights Act of 1998 (WHCRA) provides protections to patients who choose to have breast reconstruction in connection with a mastectomy, there are significant grey areas in how to interpret the law especially related to nipple-areolar tattooing. Furthermore, language describing coverage details remains vague, and in some instances may be limited to procedures that are considered “medically necessary,” further blurring potential interpretations of the law concerning nipple-areolar tattooing. Not surprisingly, coverage varies widely across private insurance companies, Medicare, and Medicaid.

Currently, Medicare pays for breast reconstruction based on the requirement of the WHCRA, however, it is not legally required to follow the WHCRA. Since Medicare is not obligated to follow the WHCRA, coverage provided to patients can change at any time. What is meant by “medical necessity” is even more unclear for Medicare and there is no strict guidance as to what this term encompasses. In addition, Medicaid does not include the requirements of the WHCRA in its mandatory requirements.

In order to achieve consistency with Medicare and Medicaid, we strongly encourage CMS to update its Medicare Medical National Coverage Determination to ensure that breast reconstruction is inclusive of nipple-areolar tattooing for each patient that is medically eligible. Furthermore, to ensure this certainty for those patients covered under Medicaid, we urge CMS to work with states to adopt the WHCRA and clearly describe nipple-areolar tattooing as a medically necessary component of reconstruction following a mastectomy.

We request CMS consider updating Medicare’s coverage and Medical National Coverage Determination to include the following WHCRA and tattooing provisions related to breast reconstruction:

  • Reconstruction of the breast that was removed by mastectomy
  • Surgery and reconstruction of the other breast to make the breasts look symmetrical or balanced after mastectomy
  • Any external breast prostheses (breast forms that fit into your bra) that are needed before or during the reconstruction
  • Any physical complications at all stages of mastectomy, including lymphedema (fluid build-up in the arm and chest on the side of the surgery)
  • Tattooing of the nipple-areolar complex:
    • State nipple-areolar complex tattooing is medically necessary as part of breast reconstruction (CPT codes 11920, 11921, 11922);
    • Covered when performed by a physician or prescribed by a physician to a licensed tattoo artist.

Sincerely,

Alcee L. Hastings                       
Member of Congress

Debbie Wasserman Schultz
Member of Congress

Jackie Walorski
Member of Congress

Lance Gooden
Member of Congress

Nydia Velázquez
Member of Congress

Jim Hagedorn
Member of Congress

J. Luis Correa
Member of Congress

Aumua Amata Radewagen
Member of Congress

Lisa Blunt Rochester
Member of Congress

Jamie Raskin
Member of Congress

Susan Davis
Member of Congress

Barbara Lee
Member of Congress

Cynthia Axne
Member of Congress

Danny K. Davis
Member of Congress

Joyce Beatty
Member of Congress

Jackie Speier
Member of Congress

Marc A. Veasey
Member of Congress

Susan W. Brooks
Member of Congress

Jenniffer Gonzalez-Colón
Member of Congress

Dwight Evans
Member of Congress

David Scott
Member of Congress

Frederica Wilson
Member of Congress

Anthony G. Brown
Member of Congress

André Carson
Member of Congress

Kathy Castor
Member of Congress

Debbie Mucarsel-Powell
Member of Congress

Vern Buchanan
Member of Congress

Val Butler Demings
Member of Congress

Darren Soto
Member of Congress

Congressman Alcee L. Hastings serves as Vice-Chairman of the House Rules Committee, Chairman of the U.S. Helsinki Commission, and Co-Chairman of the Florida Delegation.

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