Denied for DIEP Flap Surgery? Here’s What You Need to Know

DIEP flap surgery is a complex, highly specialized type of breast reconstruction often chosen by breast cancer survivors after mastectomy. It uses your own abdominal tissue to rebuild the breast, while preserving muscle and offering more natural results than traditional reconstruction options. But despite its clinical benefits, many patients are now being denied this surgery by their health insurance plans.

This guide breaks down why these denials are happening, what your rights are under federal and state law, and how to appeal if your claim was denied.

What Is DIEP Flap Surgery, and Why Do Patients Choose It?

DIEP stands for Deep Inferior Epigastric artery Perforator flap. This reconstructive procedure transfers skin and fat from the lower abdomen to the chest to rebuild the breast after mastectomy—without taking any abdominal muscle.

Unlike TRAM flap surgery, which sacrifices muscle, DIEP is muscle-sparing, which can reduce complications, improve recovery, and preserve core strength.

Some plastic surgeons may also perform nerve coaptation during DIEP, attempting to reconnect nerves in the chest wall and abdomen to help restore sensation. While not standard in every surgery, this is another clinical reason patients may prefer DIEP over older techniques.

Why Are DIEP Claims Being Denied?

In 2023, the Centers for Medicare & Medicaid Services (CMS) retired billing code S2068, which had allowed insurers to reimburse DIEP flap surgeries at a rate that reflected their complexity. Now, most insurers direct providers to use generic code 19364, which significantly reduces reimbursement—often below the cost of care.

This policy change has had a ripple effect:

• Some surgeons stopped offering DIEP to insured patients due to low reimbursement
• Insurers claim DIEP is “not medically necessary” if alternative options (e.g., TRAM flap, implants) are covered
• Patients are denied coverage or pressured into procedures they didn’t choose

In some cases, denials rely on internal medical necessity criteria or utilization review logic. However, in states like New York, insurance regulators have ruled that insurers cannot deny DIEP solely based on internal criteria if a qualified surgeon deems the surgery appropriate for the patient.

Read: NY Department of Financial Services Guidance

Even When Covered, Network Access May Be the Real Barrier

Even when DIEP is covered, many patients struggle to find an in-network surgeon qualified to perform it. DIEP requires specialized microsurgical training and hospital privileges at a facility with proper equipment and support.

Common network issues:

• Only one surgeon is in-network, but the second assisting surgeon is out-of-network
• Hospital is in-network, but the surgeon team is not
• No qualified DIEP providers exist within your insurer’s approved network radius

This is where network adequacy standards come into play. If your plan doesn’t offer access to the medically necessary providers you need, you may be entitled to a GAP exception.

What Is a GAP Exception?

A GAP exception allows you to see an out-of-network provider at in-network benefit levels when:

• Geographic Gap: No in-network DIEP surgeons exist within a reasonable travel distance (usually 30–60 miles)
• Clinical Gap: No in-network surgeon has the expertise to perform the specific procedure (like DIEP with nerve preservation)

Tip: Ask your insurer in writing:
"Can you provide the name of an in-network DIEP surgeon with hospital privileges able to perform this procedure in my area?"

If they cannot, request a GAP exception—or appeal a denial.

What the Law Says: WHCRA and State Protections

The Women’s Health and Cancer Rights Act (WHCRA) requires most group health plans to cover:

• All stages of reconstruction after mastectomy
• Procedures to achieve symmetry
• Treatment for complications, including revision surgeries

WHCRA doesn’t name specific types of reconstruction (like DIEP), but many courts and regulators have interpreted it to support patient choice when medically appropriate.

Some states go further:

• New York, California, Texas, and others have their own mandates requiring coverage of medically appropriate reconstruction methods selected by the patient and surgeon.
• Some states prohibit denials based solely on cost or internal policy criteria.

Full list of state laws on breast reconstruction

What You Can Do If You’ve Been Denied DIEP Coverage

1. Request a written denial with explanation
2. Obtain your plan documents and internal medical policy
3. Ask your surgeon to submit a clinical letter of necessity
4. Request a GAP exception if no qualified providers exist in-network
5. File a formal appeal citing: WHCRA, state protections, expert recommendations, and impact on your health
6. Use EZ Med Appeal to generate a personalized appeal letter

FAQ

Is DIEP covered by insurance? Usually, yes—but reimbursement changes often trigger denials or reduced access.

Can my plan force me to get TRAM or implants? No. WHCRA protects medically appropriate patient choice.

What if no DIEP surgeons are in-network? Request a GAP exception, and appeal if denied.

Does Medicare cover DIEP? Yes, but CMS billing policies affect reimbursement.

Sources

• CMS.gov: WHCRA
• Breastcancer.org
• DFS NY Insurance Guidance

Bottom Line

DIEP flap surgery is medically necessary for many breast cancer survivors. If denied, don’t give up. Appeal confidently—with help from EZ Med Appeal.

👉 Visit www.EZMedAppeal.com to start your appeal