Current Policy Priority

WHCRA Modernization Bill Will Ensure Coverage of Breast Reconstruction for Previvors

Social media posts asserting that individuals undergoing prophylactic mastectomy will lose access to breast reconstruction have raised alarm in the community. We are releasing this statement to put these concerns to rest. Recently introduced legislation aimed at modernizing the Women’s Health and Cancer Rights Act (WHCRA) will ensure that survivors and previvors have access to breast reconstruction, prostheses, and related care such as treatment for complications and lymphedema.

In mid-October, we learned that the American Society of Plastic Surgeons (ASPS) was spearheading the Advancing Women’s Health Coverage Act, legislation aimed at improving the Women’s Health and Cancer Rights Act (WHCRA). Passed in 1998, WHCRA is a federal law that requires most group and individual health plans that cover mastectomies to also provide coverage for breast reconstruction and related medical services. Although FORCE and other organizations were given an overview of the bill’s main provisions and invited to participate in a stakeholder briefing, we would have preferred to be engaged in the initial drafting of the legislation. The full text of the bill was not made available to us until it was formally introduced by Representative Kat Cammack and other cosponsors.

Upon reviewing the bill language, we saw a critical issue: the existing WHCRA law requires coverage of “reconstructive surgery following mastectomies.” In an effort to extend coverage to those undergoing reconstruction after a lumpectomy, the new bill replaced this language with “coverage of certain items and services…furnished in connection with breast cancer treatment.” This revision would jeopardize care for millions of women who are not diagnosed with cancer but choose to have risk-reducing (also known as “prophylactic”) mastectomies.

We contacted ASPS to express our concerns, indicating that the Advancing Women’s Health Coverage Act could not move forward with the existing language. They responded immediately, offering to meet and collaborate on a solution. On Monday, November 3, representatives from FORCE, the National Society of Genetic Counselors and National Comprehensive Cancer Network (NCCN) met with ASPS leadership. During this meeting, ASPS acknowledged that the text could be misinterpreted, leading to coverage challenges for individuals undergoing prophylactic mastectomies, and readily agreed to work with us to remedy the issue. Of note, they met with our partner, Susan G. Komen, earlier that day to discuss potential medical coding fixes.

ASPS asked FORCE to review proposed bill revisions to ensure the needs of the previvor community were fully addressed. We worked with key partners and provided updated language to ensure that risk-reducing mastectomies and aesthetic flat closure are covered under the legislation. ASPS and the congressional sponsors agreed to all the proposed revisions related to coverage of reconstruction and custom prostheses following prophylactic mastectomies. Regarding aesthetic flat closure, they are working to identify a solution that guarantees this “reconstructive” option is covered—either through the updated legislation or by establishing a new or revised CPT (billing) code.

ASPS has shown good faith and sincerity in our interactions and is working with the bill sponsors to adopt nearly all our recommended changes. As a result, both survivors and previvors will have access to a full range of evidence-based breast reconstruction options, prostheses, and related care—including treatment of lymphedema and other complications. The revised legislation will soon be introduced, replacing the original bill.

*A previvor is a person with a predisposition (high risk) for cancer.