Breast Form Facts
There are hundreds of prostheses made by companies who are dedicated to creating products for breast cancer patients. They tirelessly innovate, to help women look and feel their best. If you have been searching online, you already know the choices are endless. So how do you find the best prosthesis for you?
Breast prostheses are made from silicone and non-silicone materials and come in a spectrum of blush and darker tones. They come in varying profiles which include shallow, average and full. From my Mammographer's perspective, I can assure you age does not always determine the profile of woman’s breast. Hormones can give older breasts a dense, perky look! However, usually with age comes a shallower profile with more ‘drape’ (not DROOP, as one of my patients once told me!). Get the picture?
Prostheses come in many shapes such as heart, oval, teardrop and triangle. However, most fittings are done with the triangle (symmetrical) shape. A prosthesis is either symmetrical or asymmetrical. An asymmetrical form has an elongated side that fills in excised skin under the axilla.
Some breast forms are scientifically engineered with cooling technology. Others can be self-adhering to the chest wall or have backings with moldable gels to conform to your surgery site. Breast forms come in varying weights. Weight is a critical issue for you since you need to retain the body balance of having two breasts. Your Fitter will be able to assess which form works best for you.
The majority of breast forms have a polyurethane casing filled with traditional gel or ‘whipped’ gel, which has air incorporated to produce a form that weighs less than traditional gel. There is also a 100% silicone form, which I love, if the product is the right one for you.
A prosthesis is a highly engineered product that has undergone rigorous research and development (R&D). Medicare and other payers (Blue Cross/Blue Shield, Aetna, Cigna, etc.) categorize a prosthesis as Durable Medical Equipment (DME). A breast care boutique goes through arduous and costly governmental and bureaucratic processes in order to sell DME.
My unique perspective includes the buying side and the selling side of breast care DME products and I have lots of information to share.
Let’s talk about Medicare: DME is a very complex industry. Medicare reimbursement to your DME provider varies from state to state. Reimbursement to your dealer is pre-determined by an annual fee schedule. Here is a very simplified example of how this industry works:
The boutique owner knows, from the Medicare fee schedule, that he/she will get reimbursed $300 for silicone breast form (more or less depending on the state). Does she give you the breast form that costs her $60 or the one that costs $160 (due to special features like cooling technology mentioned above)? The Chevy or the Cadillac? The Chevy is a basic form. The Cadillac has some pretty nifty ‘bells and whistles’. Your Fitter should always fit with the most perfect outcome in mind. But she doesn’t always have the choices to accomplish that task since business owners also have to consider their profit margins and the cost of overhead. OR the business may be content to fit you with a basic form achieving a good outcome but chooses not to offer forms that have those ‘bells and whistles’. The majority of Fitters are amazing and giving souls, who want to help women feel and look like themselves, after dealing with a breast cancer diagnosis. You should be given some options and choices for a breast prosthesis. But these businesses have to be financially realistic or they may close, as many have done in the recent past.
Other payers (Blue Cross Blue Shield, Aetna, CIGNA, etc.) typically follow Medicare guidelines but may have their own. Reimbursement from these insurers are ‘all over the place’ depending on contracts with the DME and reimbursement criteria. Waaaaaay too complicated to discuss, but I hope you are getting the message here! It is critical that you call your insurance company to find out your benefits and it helps to have the Medicare billing codes when you call, since insurance companies often locate benefits with these codes. Think of it as the generic drug vs. the brand drug…insurance is often the driver of your product choices. Fitters are dedicated professionals who want to serve you and your needs. But they have to consider the business side of product choices.
Do you know how to write a prescription for breast care products? Your local DME should be able to provide a template. If not, my service can help you. The ‘Detailed Dispensing Order’ criteria for these products has dramatically changed over the past few years. Your DME dealer cannot fit your patient until they have a completed order. An incomplete order will delay delivery of bras and breast forms to your patient. I have given countless in-services to medical practices of all specialties in order to help them understand the product choices and their application to patients who have undergone lumpectomy, mastectomy, and reconstruction. I would like to help you help your patients, with industry information and knowledge.
Benefit coverage changes constantly and is different with every payer and state. Pink Ribbon Plus cannot be responsible for changes in coverage. All information is given with the sole intent to educate the client and help them understand post-breast cancer diagnosis insurance benefits when pertaining solely to post-op garments, external breast forms, bras, wigs, and skin care products. All products must be approved by the physician before using.