Prophylactic mastectomy may be considered medically necessary in patients with increased risk of breast cancer. One or more of the following risk factors constitutes an increased risk of breast cancer:

Risk Factors

• Two or more first-degree relatives with breast cancer
• One first-degree relative and two or more second-degree or third-degree relatives with breast cancer
• One first-degree relative with breast cancer before the age of 45 years and one other relative with breast cancer
• One first-degree relative with breast cancer and one or more relatives with ovarian cancer
• Two second-degree or third-degree relatives with breast cancer and one or more with ovarian cancer
• One second-degree or third-degree relative with breast cancer and two or more with ovarian cancer
• Three or more second-degree or third-degree relatives with breast cancer
• One first-degree relative with bilateral breast cancer
• Presence of a BRCA1 or BRCA2 mutation in the patient consistent with a BRCA 1 or 2 mutation in a family member with breast or ovarian cancer
• Family history with or without breast lesions associated with an increased risk, including but not limited to atypical hyperplasia or breast cancer diagnosed in the opposite breast
• Patients with such extensive mammographic abnormalities (i.e., calcifications) that adequate biopsy is impossible
• Patients with a personal history of breast cancer in the contralateral breast. (There is no time limit imposed on the prophylactic mastectomy.)

Prophylactic mastectomy for patients without one or more of the aforementioned risk factors will be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

Coverage for reconstructive breast surgery is provided for patients undergoing covered prophylactic mastectomies.

NOTE:

See Medical Policy Bulletin S-129 for additional information on mastectomy and reconstructive surgery.

Place of Service: Inpatient

Description

Prophylactic mastectomy (19303, 19304) is defined as the removal of the breast in the absence of malignant disease. Prophylactic mastectomies may be performed in women considered at high risk of developing breast cancer, either due to a family history, presence of a BRCA1 or BRCA2 mutation, or the presence of lesions associated with an increased cancer risk. Such lesions include atypical hyperplasia and lobular carcinoma in situ (LCIS). Although LCIS is labeled as a cancer, it is thought not to have invasive potential, but patients with LCIS are at increased risk of developing an invasive breast cancer elsewhere in either breast. Therefore, bilateral prophylactic mastectomy is performed not to excise the LCIS lesion itself, but to eliminate the risk of cancer arising elsewhere. Prophylactic mastectomies are typically bilateral, but can also describe a unilateral mastectomy in a patient who has previously undergone a mastectomy in the opposite breast for an invasive cancer.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

National Blue Cross Blue Shield Association Medical Policy 7.01.09, Prophylactic Mastectomy, 02:2003

InterQual® Level of Care Criteria 2010. Acute Care Adult. McKesson Health Solutions, LLC.