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STATE | ASPS Calls on Utah to Maintain Medicaid Coverage for Breast Cancer Reconstruction

In September 2017, the Utah Department of Health proposed a rule to amend the state's Medicaid policy for reconstructive and cosmetic procedures. This amendment sought to limit coverage for reconstructive surgeries to initial occurrences and proposed that Utah Medicaid not cover repeat procedures. Currently, Utah's Medicaid Policy for Reconstructive and Cosmetic Procedures lists reconstructive or restorative services as medically necessary and performed on abnormal structures of the body to improve and restore bodily function or to correct deformity resulting from disease, trauma, congenital anomaly, or previous therapeutic intervention. The initial proposal also removed "or therapeutic intervention" from the list, thus further restricting Medicaid enrollees' access to critical reconstructive care.

As the amended regulation is in direct conflict with the Society's mission, comments were submitted by ASPS in September urging the department to maintain Medicaid coverage for breast reconstruction surgeries for women in need. Additionally, the introduction of this proposal brought forth many questions of how Utah would implement the new rule. For example, the FDA recommends replacement of broken implants. However, if Utah were to limit breast reconstruction coverage to initial occurrences, it is unclear whether the state would ignore FDA guidelines by not covering replacement.

Following ASPS's September comments, the department released a revised proposal that reinstated "previous therapeutic intervention." However, ASPS submitted a second letter to the department in December expressing serious concerns language that limits reconstructive procedures to initial occurrences and does not cover repeat procedures. Ultimately, the Utah Health Department adopted the second proposal in January 2018, which provides for reconstructive services to correct previous therapeutic intervention, but limits reconstructive breast surgeries to initial occurrence and does not cover repeat procedures.

Since the adoption of this new regulation, ASPS has been in contact with the Utah Medical Association on opportunities to revise the law and ensure that patients have access to the reconstructive procedures they deserve. ASPS is also working to build a coalition of breast cancer advocates to further pressure the Utah Health Department to revisit the 2018 regulation.

Given the fact that the Breast Cancer Patient Education Act (BCPEA) was signed into law less than two years ago, it is worrisome to witness states work to decrease access and awareness surrounding reconstructive options. ASPS does not believe that cutting costs at the expense of vulnerable populations is the answer to any problem and further state action seeking to diminish the efforts of the BCPEA or Women's Health and Cancer Rights Act of 1998 will be monitored and responded to accordingly.

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