Breast Cancer and Health Insurance: What's Covered and What's Not

  |   By Elisabeth Dale

What’s the one body part Medicare won’t pay to replace with a custom made prosthesis? You guessed it, a woman’s breast.

Insurance, in most cases, does pay for a non-custom prosthetics and/or surgical reconstruction (using implants or existing muscle and fat to build a new breast). But reconstruction isn’t an option for everyone, nor is it a simple procedure or without possible medical complications. That may be why only 30% of eligible patients choose breast reconstruction.

It could also be due to a lack of awareness about options. The American Society of Plastic Surgeons recently announced an initiative to pass a bill that would require greater breast cancer patient education regarding breast reconstruction. They are launching this campaign in October, and with the help of pop singer Jewel will stage the first annual Breast Reconstruction Awareness (BRA) Day. But another bill, the Breast Cancer Patient Equity Act of 2011, which mandates Medicare coverage for custom made breast prosthetics is stalled in committee and has little, if any, chance of passing. Why? Because Medicare considers such custom replacements “not medically necessary.”

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What’s the difference between a custom and non-customized choice? Back in the 1970s, before reconstructive surgery was available, my mother received a standard breast form to wear after her radical mastectomy. I’d often find it sitting on her bedroom dresser. These external, off-the-shelf, forms can feel like bags of sand and are limited in size and shape. They must be worn with special pocketed mastectomy bras or swimwear, which are not always easy to find or available in a variety of styles and sizes.

Irene Healey, founder of New Attitude, one of several companies specializing in custom made breast prostheses, knows how the non-surgical restoration of breast symmetry changes the quality of a woman’ life. It is easier to fashion a duplicate body part using a lightweight form that fits an individual’s physical and aesthetic needs. Whether replacing tissue lost from a lumpectomy, partial, or full mastectomy, each woman receives individual care and attention. In contrast, non-customized external forms are weighted and don’t move with a woman’s body. “There’s a great deal of variety in surgical sites and a custom form provides a more dynamic, functional fit,” says Healey. Patient testimonials are clear on the differences.

Medicare’s lack of coverage of custom made breast prostheses hits the very population most at risk of developing breast cancer: aging women. Older men don’t face the same discrimination when it comes to replacing any of their non-functioning body parts. Why should women?

Want to see the Breast Cancer Equity Act passed? Sign the on-line petition here and let your Congressperson know you support a woman’s right to equal medical coverage.

Image Credit: Amoena Weighted Leisure Form

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