Highmark Commercial Medical Policy - Pennsylvania

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Medical Policy: S-163-015
Topic: Prophylactic Mastectomy
Section: Surgery
Effective Date: December 4, 2017
Issue Date: August 6, 2018
Last Reviewed: July 2018

Prophylactic mastectomy is defined as the removal of the breast in the absence of malignant disease. Prophylactic mastectomies may be performed in women considered at high risk of developing breast cancer, either due to a family history, presence of a BRCA1, BRCA2, or PALB2 gene mutation, or the presence of lesions associated with an increased cancer risk.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Prophylactic mastectomy may be considered medically necessary when ONE or more of the following risk factors are present:

  • Those with a strong family history of breast cancer such as:
    • Having a mother, sister, and/or daughter who was diagnosed with bilateral breast cancer or with breast cancer before age 50 years; or
    • A family 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); or
  • Individual has tested positive for BRCA1, BRCA2, or PALB2 gene mutations; or
  • High-risk histology: Atypical ductal or lobular hyperplasia, or lobular carcinoma in situ confirmed on biopsy; or
  • Strong family history, or no demonstrable gene mutations; or
  • Individuals with such extensive mammographic abnormalities (i.e., calcifications), or dense breasts;
  • Individuals with a personal history of breast cancer making it more likely to develop a new cancer in the opposite breast; or  
  • Li-Fraumeni syndrome or Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome; or
  • Received radiation therapy to the thoracic region before the age of 30. (e.g. radiation to treat Hodgkin’s disease); or
  • Individuals with lobular carcinoma in situ (LCIS) plus a family history of breast cancer.

Mastectomy of the contralateral breast may be considered medically necessary when ONE or more of the following situations exists:

  • For risk reduction in individuals at high risk for a contralateral breast cancer as stated above; or
  • For individuals in whom subsequent surveillance of the contralateral breast would be difficult such as for:
    • Dense breast tissue as shown clinically or mammographically; or
    • Diffuse and/or indeterminate calcifications; or
  • For improved symmetry in individuals undergoing mastectomy with reconstruction for the index cancer who:
    • Have a large and/or ptotic contralateral breast; or
    • Disproportionately sized contralateral breast.

Coverage for reconstructive breast surgery is provided for individuals undergoing covered prophylactic mastectomies.

Prophylactic mastectomy for individuals without one or more of the aforementioned risk factors will be denied as not medically necessary.

Procedure Codes
19303, 19304

 Refer to medical policy S-129 Mastectomy and Reconstructive Surgery for additional information.

Place of Service: Inpatient

The policy position applies to all commercial lines of business

Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.


Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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