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.