1.0 CPT
PROCEDURE CODES
19300 - 19307, 58150 - 58294,
58541 - 58554, 58661, 58720, 58940 - 58956
2.0 DESCRIPTION
Prophylactic mastectomy, prophylactic
oophorectomy, and prophylactic hysterectomy are surgical procedures
that aim at completely removing organs or tissue in the absence
of malignant disease to reduce the risk of individuals at high risk
from developing cancer. A high risk individual is one with a family
history of cancer in the breast and/or ovaries, or uterus; or personal
history of cancer in the breast and/or ovaries. Carefully selected
indications have been developed for prophylactic mastectomy and
are included in this policy.
3.0 POLICY
3.1 Bilateral
prophylactic mastectomies are covered for patients at increased
risk of developing breast carcinoma who have one or more of the
following:
3.1.1 Atypical hyperplasia of lobular or ductal origin
confirmed on biopsy; or
3.1.2 A 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). A positive Breast Cancer (BRCA) genetic test is not necessary;
or
3.1.3 Fibronodular, dense breasts which are mammographically
and/or clinically difficult to evaluate and the patient presents
with either of the above (or both) clinical presentations.
3.2 Unilateral
prophylactic mastectomies are covered when the contralateral breast
has been diagnosed with cancer for patients with:
3.2.1 Diffuse microcalcifications
in the remaining breast, especially when ductal in-situ carcinoma
has been diagnosed in the contralateral breast; or
3.2.2 Lobular
carcinoma in-situ; or
3.2.3 Large breast and/or ptotic,
dense or disproportionately-sized breast that is difficult
to evaluate mammographically and clinically; or
3.2.4 In whom
observational surveillance is elected for lobular carcinoma in-situ
and the patient develops either invasive lobular or ductal carcinoma;
or
3.2.5 A 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). A positive BRCA
genetic test is not necessary.
3.3 Prophylactic oophorectomy is covered for women
who meet any of the following criteria:
3.3.1 Women who have been diagnosed with an hereditary
ovarian cancer syndrome based on a family pedigree constructed by
an authorized provider competent in determining the presence of
an autosomal dominant inheritance pattern; or
3.3.2 Women with a personal history of steroid hormone
receptor-positive breast cancer; or
3.3.3 Women with a personal history of breast cancer
and at least one first degree relative (mother, sister, daughter)
with a history of ovarian cancer; or
3.3.4 Women who have two or more first degree relatives
with a history of breast or ovarian cancer;
or
3.3.5 Women with
one first degree relative and one or more second degree relative (grandmother,
aunt, or niece) with ovarian cancer.
3.3.6 Some families have pedigrees that are very
small, and therefore have only one first degree relative with ovarian
cancer or young-onset breast, colon, or endometrial cancer that
may suggest increased risk for ovarian cancer. These individuals
may also be considered for prophylactic oophorectomy. Effective
January 1, 2006.
3.4 Prophylactic hysterectomy is covered:
3.4.1 For women who are about to undergo or are undergoing
tamoxifen therapy.
3.4.2 For women who have been diagnosed with Hereditary
Non-Polyposis Colorectal Cancer (HNPCC) or are found to be carriers
of HNPCC-associated mutations.