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, or PALB2 gene mutation, or the presence of lesions associated with an increased cancer risk.
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:
- Having a mother, sister, and/or daughter who was diagnosed with bilateral breast cancer or with breast cancer before age 50 years; or
- 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); or
- Individual has tested positive for BRCA1, BRCA2, or PALB2 gene mutations; or
- High-risk histology: Atypical ductal or lobular hyperplasia, or lobular carcinoma in situ confirmed on biopsy; or
- Strong family history, or no demonstrable gene mutations; or
- Individuals with such extensive mammographic abnormalities (i.e., calcifications), or dense breasts;
- Individuals with a personal history of breast cancer making it more likely to develop a new cancer in the opposite breast; or
- Li-Fraumeni syndrome or Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome; or
- Received radiation therapy to the thoracic region before the age of 30. (e.g. radiation to treat Hodgkin’s disease); or
- Individuals with lobular carcinoma in situ (LCIS) plus a family history of breast cancer.
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 individuals without one or more of the aforementioned risk factors will be denied as not medically necessary.