Mastectomy

A mastectomy, total or partial, is a covered benefit when medically necessary for treatment of breast cancer.

Bilateral prophylactic mastectomies are covered for patients with an increased risk of developing breast cancer who have fibronodular, dense breasts which are mammographically and/or clinically difficult to evaluate, and one or more of the following:

• atypical hyperplasia of lobular or ductal origin confirmed on biopsy
• history of breast cancer in multiple first-degree relatives*
  
• history of breast or ovarian cancer, also known as Family Cancer Syndrome, in multiple successive generations of family members*

Unilateral prophylactic mastectomies are covered when the contralateral breast has been diagnosed with cancer for patients with:

• diffuse microcalcifications in the remaining breast, especially when ductal in-situ cancer has been diagnosed in the contralateral breast;
• lobular cancer in-situ;
• large breast and/or ptotic, dense or disproportionately-sized breast that is difficult to evaluate mammographically and clinically;
• in whom observational surveillance is elected for lobular cancer in-situ and the patient develops either invasive lobular or ductal cancer;
• a history of breast cancer in multiple first-degree relatives;* or
• a history of breast or ovarian cancer, also known as Family Cancer Syndrome, in multiple successive generations of family members.*

*A positive breast cancer genetic test (BRCA) is not required.

To expedite the review process, providers may attach a Letter of Attestation in lieu of clinical documentation to the authorization request. 

If covered, the setting where the services are provided will determine costs; ambulatory surgery center or inpatient hospital setting.