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.