HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
S-163-022
Topic:
Prophylactic Mastectomy
Section:
Surgery
Effective Date:
October 1, 2024
Issued Date:
October 1, 2024
Last Revision Date:
September 2024
Annual Review:
June 2023
 
 

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 Position

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 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 from an appropriate provider such as a 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 not meeting the criteria as indicated in this policy is considered not medically necessary.

19303

 

 

 

 

 

 


Related Policies

Refer to medical policy, S-129 Mastectomy and Reconstructive Surgery, for additional information.


Covered diagnosis codes for procedure codes 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


Place of Service: Inpatient


The policy position applies to all commercial lines of business



Links





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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.