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Coverage criteria policies

Prophylactic Mastectomy

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for prophylactic mastectomy.

Coverage

Prophylactic simple mastectomy (unilateral or bilateral) for the reduction of breast cancer risk is generally covered subject to the indications listed below.

Indications that are covered

  1. For women with any of the following conditions:
    1. Personal history of breast cancer; or
    2. Personal history of a cancer predisposition syndrome known to be associated with an increased risk of breast cancer, confirmed by genetic testing. See Genetic Testing for Cancer Predisposition Policy for a list of allowable syndromes; or
    3. History of radiation treatment to the chest between ages 10 and 30 years, (such as for treatment for Hodgkin’s disease); or
    4. Background ethnicity is known to be associated with a higher incidence of breast cancer (e.g. Ashkenazi Jewish) and who have at least 1 relative with a history of either breast or ovarian cancer
  2. For women with a strong family history as evidenced by one of the following:
    1. Multiple primary or bilateral breast cancers in a first or second degree blood relative; or
    2. A first-, second-, or third-degree blood relative with a cancer predisposition syndrome known to be associated with an increased risk of breast cancer, confirmed by genetic testing; or
    3. Breast cancer in a first or second degree male relative; or
    4. Breast cancer in a first or second degree relative, in addition to ovarian cancer in a first or second degree relative on the same side of the family; or
    5. Breast cancer in 3 or more first or second degree blood relatives on the same side of the family; or
  3. For men with a personal history of breast cancer, prophylactic mastectomy of the contralateral breast is covered.

Breast reconstruction following a prophylactic mastectomy is covered per the breast reconstruction coverage guidelines (See breast surgery coverage criteria).

Indications that are not covered

  1. Prophylactic subcutaneous mastectomy is generally not covered as a percentage of breast tissue remaining may later develop cancer.
  2. Prophylactic mastectomy for men with a family history, but without a personal history of breast cancer, is not covered as the clinical value has not been established.

Definitions

First-degree relative is an individual’s parent, sibling, or child

Second-degree relative is an individual’s grandparent, grandchild, aunt, uncle, nephew, niece, or half-sibling.

Third-degree relative is an individual’s first cousin, great-grandparent, great-grandchild, great-aunt, great-uncle, grandniece, grandnephew, half-aunt, half-uncle, half-nephew, or half-niece.

Prophylactic mastectomy is the surgical removal of one or both breasts as a measure to prevent the development or spread of disease.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Hayes, Inc. Hayes Medical Technology Directory Report. Risk-Reducing (Prophylactic) Mastectomy. Lansdale, PA: Hayes, Inc.; December, 2013. Reviewed November, 2016.

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Policy activity

  • 01/01/1994 - Date of origin
  • 01/01/1994 - Effective date
Review date
  • 12/2017

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