Prophylactic Mastectomy

Policy ID: S-163-022

Section: Surgery

Effective Date: November 01, 2019

Revised Date: September 25, 2024

Revision Effective Date: October 01, 2024

Last Reviewed: September 17, 2024

Applies To: Commercial and Medicaid Expansion

Description

Prophylactic mastectomy 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, BRCA2, TP53, PTEN, PALB2, CDH1, STK11 gene mutation, or another gene variant associated with high risk; or the presence of lesions associated with an increased cancer risk.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Prophylactic mastectomy may be considered medically necessary when ONE or more of the following risk factors are present:

Those with a strong family history of breast cancer such as:
- A family history of breast cancer in multiple first-degree relatives and/or multiple successive generations of family members with breast and/or ovarian cancer (family cancer syndrome); and
- The individual's risk of breast cancer is elevated on a validated assessment tool such as the Breast Cancer Risk Calculator, Gail Model, or Tyrer-Cuzick Risk Calculator; and
- The individual has undergone counseling form an appropriate provider such as gynecologist, breast surgeon or genetic counselor to quantitate their risk; or
Individual has tested positive for BRCA1, BRCA2, TP53, PTEN, PALB2 , CDH1, STK11 gene mutations; or another gene variant associated with high risk; or
High-risk histology: Atypical ductal or lobular hyperplasia, or lobular carcinoma in situ confirmed on biopsy; or
Individuals with such extensive mammographic abnormalities (e.g., calcifications), cystic/dense breast tissue) that adequate biopsy is impossible; or
Individuals with a personal history of breast cancer making it more likely to develop a new cancer in the opposite breast; or
Individuals who received radiation therapy to the thoracic region before the age of 30 (e.g. radiation to treat Hodgkin's disease) .

Mastectomy of the contralateral breast may be considered medically necessary when ONE or more of the following situations exists:

For risk reduction in individuals at high risk for a contralateral breast cancer as stated above; or
For individuals in whom subsequent surveillance of the contralateral breast would be difficult such as for:
- Dense breast tissue as shown clinically or mammographically; or
- Diffuse and/or indeterminate calcifications; or
For improved symmetry in individuals undergoing mastectomy with reconstruction for the index cancer who:
- Have a large and/or ptotic contralateral breast; or
- Disproportionately sized contralateral breast.

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

Prophylactic mastectomy for any other reason is considered not medically necessary.

Procedure Code

19303

Diagnosis Codes

Covered Diagnosis codes for Procedure code 19303

D05.00

D05.01

D05.02

D05.10

D05.11

D05.12

D05.80

D05.81

D05.82

D05.90

D05.91

D05.92

E71.440

R92.1

R92.8

Z15.01

Z17.410

Z17.420

Z40.01

Z80.3

Z85.3

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-26-2019 Coding update

Internal Medical Policy Committee 5-19-2020 Annual Review

Internal Medical Policy Committee 11-19-2020 wording changes

Internal Medical Policy Committee 11-23-2020 Annual Review-no changes in criteria

Internal Medical Policy Committee 3-23-2022 Revision

Update in criteria and clarifying language

Internal Medical Policy Committee 3-23-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 7-26-2023 Revision

Updated language throughout policy
- Added CDH1, STK11 gene mutations or another gene variant associated with high risk'.

Internal Medical Policy Committee 7-16-2024 Annual Review-no changes in criteria

Added coverage statement; and
Added Policy Application

Internal Medical Policy Committee 9-17-2024 Coding update- Effective October 01, 2024

Added diagnosis codes Z17.410 and Z17.420

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-163-021