I 
115TH CONGRESS 
2D SESSION 
H. R. 6980 
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 
SEPTEMBER 28, 2018 
Mr. BLUM (for himself and Ms. JUDY CHU of California) introduced the fol-
lowing bill; which was referred to the Committee on Energy and Com-
merce, and in addition to the Committee on Ways and Means, for a pe-
riod to be subsequently determined by the Speaker, in each case for con-
sideration of such provisions as fall within the jurisdiction of the com-
mittee concerned 
A BILL 
To amend title XVIII of the Social Security Act to provide 
coverage for custom fabricated breast prostheses fol-
lowing a mastectomy. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; FINDINGS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Breast Cancer Patient Equity Act’’. 
(b) FINDINGS.—Congress finds the following: 
(1) There are currently more than 3,500,000 
women with a history of breast cancer in the United 
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States, many of whom experience unreconstructed 
breast loss. 
(2) In 2018, more than 260,000 women were 
diagnosed with invasive breast cancer that required 
surgery, with many having to undergo surgical 
breast removal. 
(3) In 2018, more than 40,000 women in the 
United States are expected to die from breast can-
cer. 
(4) Annually, there are 144,000 women in the 
United States who undergo mastectomies, a surgical 
removal of the breast. 
(5) The number of breast mastectomies in the 
United States has increased among younger women, 
ages 18 to 34 years old, at a rate of 30 percent and 
at a rate of 15 percent for women ages 35 to 44 
years old. 
(6) The results of breast reconstruction surgery 
can vary and, as with any surgical procedure, there 
are inherent risks associated with such surgery. Ad-
ditionally, reconstruction of the breast using im-
plants can impose increased risks and costs due to 
the eventual need for implant replacement surgery. 
(7) The number of women choosing to undergo 
surgical breast reconstruction continues to increase, 
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as many women lack the viable option of custom fab-
ricated prosthetic breasts to restore the lost breast. 
(8) Both older women and minority women are 
less likely to be offered or undergo surgical breast 
reconstruction and are disproportionately disadvan-
taged by a lack of access to the option of custom 
fabricated prosthetic breasts. 
(9) Currently, the Medicare program provides 
coverage and reimbursement for custom fabricated 
prostheses for any body part, with the exception of 
breasts, that has been lost. 
(10) Following passage of the Women’s Health 
and Cancer Rights Act of 1998 (Public Law 105– 
277; 42 U.S.C. 201 note), many private insurers 
and group health plans began to provide coverage 
for custom fabricated breast prostheses as an alter-
native to surgical breast reconstruction. 
(11) While the Medicare program recognizes 
custom fabricated breast prostheses as a discrete de-
vice and valid treatment option, having assigned a 
billing code for such option under the Healthcare 
Common Procedure Coding System (‘‘HCPCS’’) and 
setting a maximum allowable fee, Medicare does not 
provide reimbursement and denies claims as ‘not 
medically necessary’. Medicare does provide reim-
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bursement, however, for more costly surgical breast 
reconstruction. 
(12) Due to the fact that the Medicare program 
does not provide reimbursement for custom fab-
ricated breast prostheses, many private insurance 
companies have also begun to limit their reimburse-
ment for them. 
(13) The Department of Veterans Affairs does 
provide the option of a custom fabricated prosthetic 
breast for women post-mastectomy. 
(14) Providing coverage for custom fabricated 
prosthetic breast devices and components will not in-
crease the incidence of breast mastectomies. 
SEC. 2. COVERAGE. 
(a) IN GENERAL.—Section 1861(s)(8) of the Social 
Security Act (42 U.S.C. 1395x(s)(8)) is amended— 
(1) by adding ‘‘and’’ after the semicolon at the 
end; 
(2) by inserting ‘‘(A)’’ after ‘‘(8)’’; and 
(3) by inserting after subparagraph (A) the fol-
lowing new subparagraph: 
‘‘(B) custom fabricated breast prostheses fol-
lowing surgical removal of the breast, including re-
placement of such prostheses;’’. 
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(b) CONFORMING AMENDMENT.—Section 1862(a)(7) 
of such Act (42 U.S.C. 1395y(a)(7)) is amended by strik-
ing ‘‘1861(s)(8)’’ and inserting ‘‘1861(s)(8)(A)’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to items and services furnished on 
or after the date of enactment of this Act. 
Æ 
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