Silicone Breast Form Facts
Confused about the terminology of silicone? This will help you understand the differences in available silicones.
1st Generation of silicone: ‘Standard’ breast form silicone is what the first forms were made of back in the mid 1900s and are the heaviest of forms. Not widely used any longer by patients but if standard silicone is comfortable for you and you do not find the weight bothersome, then stick with it! Vendors are slowly decreasing the choices of this form.
2nd Generation of silicone: “Lightweight” breast form silicone was developed in the mid 1990s. Air was whipped in with the silicone to make it about 35% lighter than ‘standard’ silicone.
3rd Generation of silicone: “Lighter than Light” weight breast form silicone is the newest variation of silicone used in breast forms. It is about 15% lighter than the 2nd generation silicone. You could also say it is 40% to 45% lighter than standard silicone.
An external silicone prosthesis (often called breast form) is a highly engineered product that has undergone rigorous research and development (R&D). These are the forms typically worn every day.
There are several manufacturers of prostheses (often called forms). These companies are dedicated to developing and designing beautiful and functional products for women who have undergone various surgeries due to a breast cancer diagnosis. They come in a variety of textures, sizes, features and benefits, and shapes. Your professional Fitter will fit you with the form that best mimics your existing breast, for unilateral surgeries, or that gives you the look and size you want in the case of bilateral surgeries.
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 rigorous 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 with you.
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. 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.