Finishing Touches: Expanding Access to Nipple-areola Tattooing as a Component of Postmastectomy Breast Reconstruction

Approximately 275,000 new cases of breast cancer are diagnosed in the United States annually, with American women carrying a 1 in 8 lifetime risk of receiving the diagnosis.¹ Postmastectomy breast reconstruction is now universally recognized as a gold standard component of comprehensive breast cancer treatment. Breast reconstruction has been proven to significantly improve a woman’s psychosocial and physical well-being through creation of a new breast mound with techniques that are both safe and effective. With these surgical advancements, the number of women pursuing breast reconstruction has trended upward. In 2018 alone, 101,657 breast reconstructive procedures were performed in the United States—a 29% increase since 2000 when 78,832 procedures were performed.² Unfortunately, over the past 2 years, there has been a 7% decline in breast reconstruction procedures performed and challenges with lack of access to reconstructive services likely contributing to this downturn.

Women who are interested in breast reconstruction usually have 3 options—external prosthesis, implant-based reconstruction, or autologous reconstruction via transfer of tissue from another area of their body. Selection varies widely and is largely dependent on the extent of a patient’s disease, reconstructive goals, and quality of tissue available for reconstruction. For example, a patient’s nipple-areola complex may need to be removed during her mastectomy because of the location of her cancer. This unfortunately results in a more obvious defect that will require additional reconstruction of the nipple-areola complex after a breast mound is created.

In a scenario such as this, the nipple-areola complex is reserved for the final stage of reconstruction, fully restoring the breast to a natural, symmetric appearance that would otherwise be incomplete. This is achieved by a combination of tattooing with or without the addition of a surgical procedure using local tissue to create a projecting nipple. Tattooing alone is at times the only option for nipple-areola reconstruction in patients who may have damaged tissue due to radiation therapy or simply want to avoid an additional surgical procedure. Most commonly, nipple-areola tattooing is performed in a surgeon’s office by either the physician or a physician extender. However, plastic and reconstructive surgeons are increasingly recognizing that professional tattoo artists can achieve superior results using sophisticated techniques, including an impressively realistic 3-dimensional nipple-areola complex tattoo.³

The Women’s Health and Cancer Rights Act (WHCRA)⁴ of 1998 broadened accessibility of breast reconstruction by requiring medical insurance carriers to cover the financial burden of reconstructive efforts following mastectomy; however, there are significant grey areas as it pertains to the law’s application to nipple-areola tattooing. In its current iteration, the legislation mandates coverage for the following indications:

• Reconstruction of the breast that was removed by mastectomy

• Surgery and reconstruction of the other breast to make the breasts look symmetrical or balanced after mastectomy

• Any external breast prostheses (breast forms that fit into your bra) that are needed before or during the reconstruction

• Any physical complications at all stages of mastectomy, including lymphedema (fluid buildup in the arm and chest on the side of the surgery)

Language describing coverage details remains vague and, in some instances, may be limited to procedures that are considered “medically necessary,” further blurring potential interpretations of the law with regard to nipple-areola tattooing. Although some excerpts supporting the medical necessity of tattooing exist, the documentation varies significantly between medical insurance providers. Not surprisingly, coverage varies widely across private insurance companies, Medicare, and Medicaid.

Another shortcoming of the WHCRA is that the requirement of coverage only applies to private group health insurance plans (employer based) and individual health insurance policies (nonemployer based), but not federal or state programs (Medicare or Medicaid). These private insurance companies are prohibited from rejecting claims for all stages of reconstruction of the breast, on which a mastectomy has been performed. As a result, the majority of private insurance companies cover nipple-areola tattooing (if performed by physicians). Blue Cross, Rhode Island, provides for broad coverage where nipple-areola tattooing is medically necessary and can not only be performed by a physician but also a tattoo artist.⁵ A further degradation of breast reconstruction coverage is that state and local governments, as well as churches, are exempted from the WHCRA.

Medicare coverage is not required under federal law but is often implemented in practice and covers the costs as outlined in the WHCRA. Because they are not legally obligated to follow the WHCRA, however, the coverage provided can change at will. Furthermore, definitions of “medical necessity” are even more unclear for Medicare and there is no strict guidance as to what this term encompasses.

When it comes to Medicaid programs, there is a significant divergence of coverage. For example, West Virginia outright does not cover nipple-areola tattooing because it is not considered “medically necessary.”⁶ Iowa imposes a time constriction where the patient must undergo reconstruction within 12 months following mastectomy to have subsequent nipple-areola tattooing covered;⁷ a contingency that does not exist under any other segment of the WHCRA. On the flip side, Louisiana approves of nipple-areola tattooing coverage because they deem it a medical necessity. North Carolina also covers all nipple-areola reconstruction as part of their Medicaid coverage including either tattooing or skin grafting (a surgical procedure) for the areola.⁸ Along similar lines, Vermont allows for nipple-areola tattooing following mastectomy or lumpectomy when it is prescribed by a licensed medical provider who is knowledgeable in the use of nipple-areola tattooing.⁹

Patients who invest in health-care insurance but whose plans/states do not recognize nipple-areola tattooing as a required component of their breast reconstruction are left to burden the expense for this final phase, which can be costly. Varying by region, pricing can start at almost $400 for a single breast and reach as high as $1,000 for both breasts. Moreover, as they branch out to tattoo artists in the community that work in a free market, the cost can be even greater.

In conclusion, the strife surrounding financial coverage of breast reconstruction achieved significant headway with passage of the WHCRA 20 years ago. However, as surgical and clinical advancements have been made to improve patient care, legislation regarding the costs and coverage of these techniques should also be updated and clarified. The nipple-areola complex is revered as the cornerstone of the aesthetic breast, and its reconstruction significantly impacts satisfaction with reconstruction, finalizing the psychological journey of a woman feeling whole again.¹⁰ Greater standardization of coverage for nipple-areola reconstruction across insurance carriers is warranted. To achieve better consistency, Medicare will need to update its medical coverage to ensure that breast reconstruction is inclusive of all nipple-areola tattooing for each patient who is eligible medically and desires it personally. To ensure this certainty for those patients covered under Medicaid, Center for Medicare and Medicaid Services should amend the list of mandatory requirements a state must follow to be compliant with WHCRA and clearly describe nipple-areola tattooing as a medically necessary component of reconstruction following a mastectomy.

The language of the current WHCRA legislation should be updated to include an important fifth indication mandating that private medical insurance carriers also cover nipple-areola tattooing. We suggest the following addition:

Tattooing of the nipple-areola complex is medically necessary and a component of breast reconstruction. Coverage for this procedure will be provided when either performed by a physician, physician extender, or licensed tattoo artist (as properly prescribed by a physician).

Additionally, language in both Medicare and Medicaid programs related to reconstruction and nipple-areola tattooing should reflect the following:

Both Medicare and Medicaid must follow the requirements in the WHCRA in relation to breast reconstruction. In addition, tattooing of the nipple-areola as part of breast reconstruction (Current Procedural Terminology [CPT] codes 11920, 11921, 11922) is considered medically necessary and covered when performed by a physician or licensed tattoo artist. When performed by a licensed tattoo artist, the physician will provide a prescription to the patient for the procedure. In most instances, the patient will pay for the procedure and then subsequently submit the receipt with the physician prescription (and diagnosis) to their medical insurance provider for full reimbursement at a competitive national average rate.

ACKNOWLEDGMENT

The authors would like to formally acknowledge the contributions and support of Lale Morrison, BA, MA, Jacqueline Hlavin, CPA, Esq., and Jennifer Butler, BA, M.Ed.