I 

111TH CONGRESS 

2D SESSION H. R. 5447 

To amend title XVIII of the Social Security Act to provide coverage for 

custom fabricated breast prostheses following a mastectomy. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 27, 2010 

Mr. ROSS introduced the following bill; which was referred to the Committee 

on Energy and Commerce, and in addition to the Committee on Ways 

and Means, for a period to be subsequently determined by the Speaker, 

in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To amend title XVIII of the Social Security Act to provide 

coverage for custom fabricated breast prostheses following a mastectomy. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE; FINDINGS. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘Custom Fabricated Prosthetic Breast Act of 2010’’. 

6 (b) FINDINGS.—Congress finds the following: 


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1 (1) There are currently 2,500,000 women in the 

2 United States living with breast cancer, many of 

3 whom suffer from unreconstructed breast loss. 

4 (2) In 2009, an estimated 192,370 women were 

5 diagnosed with invasive breast cancer that required 

6 surgery, with many having to undergo surgical 

7 breast removal. 

8 (3) Annually, there are more than 130,000 

9 women in the United States who undergo 

10 mastectomies, a surgical removal of the breast. 

11 (4) The number of breast amputations in the 

12 United States is projected to increase due to the ris13 ing incidence of breast cancer and the growing elder14 ly population. 

15 (5) A woman suffering from the loss of her 

16 breast may not be a candidate for surgical breast re17 construction or may choose not to undergo addi18 tional surgery if there were a viable, less costly, less 

19 invasive option available. 

20 (6) The results of breast reconstruction surgery 

21 can vary and, as with any surgical procedure, there 

22 are inherent risks associated with such surgery. Ad23 ditionally, reconstruction of the breast using im24 plants can impose increased risks and costs due to 

25 the eventual need for implant replacement surgery. 


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1 (7) The number of women choosing to undergo 

2 surgical breast reconstruction continues to increase, 

3 as many women lack the viable option of custom fab4 ricated prosthetic breasts to restore the lost breast. 

5 (8) Both older women and minority women are 

6 less likely to be offered or undergo surgical breast 

7 reconstruction and are disproportionately disadvan8 taged by a lack of access to the option of custom 

9 fabricated prosthetic breasts. 

10 (9) Currently, the Medicare program provides 

11 coverage and reimbursement for custom fabricated 

12 prostheses for any body part, with the exception of 

13 breasts, that has been lost. 

14 (10) Following passage of the Women’s Health 

15 and Cancer Rights Act of 1998 (Public Law 105– 

16 277; 42 U.S.C. 201 note), many private insurers 

17 and group health plans began to provide coverage 

18 for custom fabricated breast prostheses as an alter19 native to surgical breast reconstruction. 

20 (11) While the Medicare program recognizes 

21 custom fabricated breast prostheses as a discrete de22 vice and valid treatment option, having assigned a 

23 billing code for such option under the Healthcare 

24 Common Procedure Coding System (‘‘HCPCS’’) and 

25 setting a maximum allowable fee, Medicare does not 


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1 provide reimbursement and downgrades such option 

2 to a non-custom fabricated ‘‘least costly alternative’’. 

3 Medicare does provide reimbursement, however, for 

4 more costly surgical breast reconstruction. 

5 (12) Due to the fact that the Medicare program 

6 does not provide reimbursement for custom fab7 ricated breast prostheses, many private insurance 

8 companies have also begun to limit their reimburse9 ment for them. 

10 (13) Providing coverage for custom fabricated 

11 prosthetic breast devices and components will not in12 crease the incidence of breast amputations. 

13 SEC. 2. COVERAGE. 

14 (a) IN GENERAL.—Section 1861(s)(8) of the Social 

15 Security Act (42 U.S.C. 1395x(s)(8)) is amended— 

16 (1) by striking ‘‘(8) prosthetic devices’’ and in17 serting ‘‘(8)(A) prosthetic devices’’; 

18 (2) in subparagraph (A), as added by para19 graph (1), by inserting ‘‘and’’ after the semicolon; 

20 and 

21 (3) by inserting after subparagraph (A) the fol22 lowing new subparagraph: 

23 ‘‘(B) custom fabricated breast prostheses 

24 following surgical removal of the breast, includ25 ing replacement of such prostheses;’’. 


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1 (b) CONFORMING AMENDMENT.—Section 1862(a)(7) 

2 of such Act (42 U.S.C. 1395y(a)(7)) is amended by strik3 ing ‘‘eyewear described in section 1861(s)(8)’’ and insert4 ing ‘‘eyewear described in section 1861(s)(8)(A)’’. 

5 (c) EFFECTIVE DATE.—The amendments made by 

6 this section shall apply to items and services furnished on 

7 or after the date of enactment of this Act. 

Æ 


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