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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 4
Section 5.3
Prophylactic Mastectomy, Prophylactic Oophorectomy, And Prophylactic Hysterectomy
Issue Date:  October 25, 1993
Authority:  32 CFR 199.4(c)(2)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-1, March 10, 2017
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.
- END -

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