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Prophylactic Mastectomy, Oophorectomy/Salpingo-Oophorectomy, and Hysterectomy
MA11.077j

Policy

In the absence of coverage criteria from applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals, or other Medicare coverage documents, this policy uses internal coverage criteria developed by the Company in consideration of peer-reviewed medical literature, clinical practice guidelines, and/or regulatory status. ​

​PROPHYLACTIC MASTECTOMY

Prophylactic mastectomy is considered medically necessary and, therefore, covered in individuals who have a high risk or moderately increased risk of developing breast cancer.

For the criteria below, first-degree relatives include parents, children, and siblings. Second-degree relatives include grandparents, aunts, and uncles. Third-degree relatives include great-grandparents and first-degree cousins.

Individuals are considered to have a high risk for breast cancer when they have one or more of the following:
  • Two or more first-degree relatives with breast cancer
  • One first-degree relative and two or more second-degree or third-degree relatives with breast cancer
  • One first-degree relative with breast cancer diagnosed by 45 years of age and one other relative (of any degree) with breast cancer
  • One first-degree relative with breast cancer and one or more relatives (of any degree) with ovarian cancer
  • Two second-degree or third-degree relatives with breast cancer and one or more with ovarian cancer
  • One second-degree or third-degree relative with breast cancer and two or more relatives (of any degree) with ovarian cancer
  • Three or more second-degree or third-degree relatives with breast cancer
  • One first-degree relative with bilateral breast cancer
  • High risk (lifetime risk about 20% or greater) of developing breast cancer as identified by models that are largely defined by family history
  • Presence of breast risk cancer antigen (BRCA1 or BRCA2) gene mutation
  • Diagnosis of invasive ductal carcinoma (IDC) or lobular carcinoma in situ (LCIS)
  • History of exposure/treatment with thoracic radiation, especially at a young age (between 10 and 30 years of age)
  • Belonging to groups that have high prevalence of BRCA variations mainly due to their ancestral decent (e.g., Ashkenazi Jewish)
  • Li-Fraumeni​ syndrome, Cowden syndrome, Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative with one of these syndromes
  • Presence of a TP53, CDH1, STK11, PTEN, or PALB2 gene mutation
​The following individuals are considered to be at moderately increased risk for breast cancer:
  • Individuals who do not meet the definition of high risk, but nonetheless are considered at moderately increased risk based on family history with or without breast lesions associated with an increased risk, including, but not limited to, atypical hyperplasia or individuals with any type of breast cancer diagnosed in the opposite breast
  • Individuals with such extensive mammographic abnormalities (e.g., cystic/dense breast tissue, calcifications) that adequate biopsy is impossible
  • History of previous or planned mastectomy for an invasive cancer
All other uses for prophylactic mastectomy are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the treatment of illness or injury.

PROPHYLACTIC OOPHORECTOMY/SALPINGO-OOPHORECTOMY

For the criteria below, first-degree relatives include parents, children, and siblings. Second-degree relatives include grandparents, aunts, and uncles.

Prophylactic oophorectomy or salpingo-oophorectomy is considered medically necessary and, therefore, covered in individuals with high risk factors for ovarian cancer if they meet ANY of the following criteria:
  • Prescence of pathogenic or likely pathogenic gene variants (e.g., BRCA1, BRCA2) ​associated with breast and ovarian cancer
  • Individuals with a known familial cancer syndrome associated with increased risk of ovarian cancer (e.g., Lynch syndrome)
  • Individuals with a personal history of breast cancer and at least one first-degree relative with a history of ovarian cancer
  • Individuals with two or more first-degree relatives with a history of ovarian and/or breast cancer
  • Individuals with one first degree relative and one or more second degree relative with a history of ovarian cancer
  • Individuals after completion of childbearing who have been diagnosed with a hereditary ovarian cancer syndrome based on a family pedigree constructed by a genetic counselor or physician competent in determining the presence of an autosomal dominant inheritance pattern in which genetic testing is either not available or uninformative
  • Individuals with a premenopausal history of steroid hormone receptor–​positive breast cancer
Prophylactic oophorectomy or salpingo-oophorectomy for indications that do not meet the above criteria are considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

PROPHYLACTIC HYSTERECTOMY

Prophylactic hysterectomy when performed with bilateral oophorectomy is considered medically necessary and, therefore, covered in individuals if they meet ANY of the following criteria:
  • Individuals diagnosed with hereditary nonpolyposis colorectal cancer (HNPCC/Lynch syndrome), confirmed by pathogenic or likely pathogenic variations in associated genes (i.e., MLH1, MSH2, MSH6, PMS2)
  • Individuals with familial history of HPNCC​ as determined by a pattern of occurrence of HNPCC-related cancers​
  • Individuals who meet the criteria for a prophylactic oophorectomy and who, after a risk/benefit discussion with their professional provider, choose to have prophylactic hysterectomy in conjunction with oophorectomy
Prophylactic hysterectomy for indications that do not meet the above criteria are considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

There is no Medicare coverage determination addressing this service; therefore, the Company policy is applicable.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, prophylactic mastectomy, prophylactic oophorectomy/salpingo-oophorectomy, and prophylactic hysterectomy are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

Description

PROPHYLACTIC MASTECTOMY

Prophylactic mastectomy is the removal of breast tissue (unilateral or bilateral) in the absence of malignant disease to prevent breast cancer in high-risk individuals. Current research supports the efficacy of prophylactic mastectomy in individuals who, when compared with the general population, are determined to be at increased risk (high risk or moderate risk) for breast cancer. Increased risk is based upon a formal evaluation of family history using appropriate risk-assessment procedures.

Individuals at an increased risk for developing breast cancer include those with an extensive family history of breast cancer (i.e., a history of early-onset disease), women with ovarian cancer occurring in multiple generations, individuals who have the breast cancer risk antigen BRCA1 or BRCA2 gene mutation, individuals with TP53, CDH1, STK11, PTEN, or PALB2 gene mutations, individuals with prior history of thoracic radiation, and individuals who have breast lesions associated with an increased cancer risk (e.g., atypical hyperplasia, lobular carcinoma in situ [LCIS]), invasive ductal carcinoma [IDC]).

While high risk is more objectively defined by family history or the presence of a BRCA1 or BRCA2 gene mutation, moderate risk may be conferred by a wide range of family histories in association with different types of breast pathologies.

Typically, prophylactic mastectomy is bilateral, but it can be unilateral when performed in an individual who has previously undergone or is presently undergoing a mastectomy in the opposite breast for an invasive cancer.

Prophylactic mastectomy is defined as either total (simple) mastectomy or subcutaneous mastectomy. Total mastectomy is the removal of the entire breast and nipple-areolar complex. Subcutaneous mastectomy is the removal of the breast tissue, but the nipple-areolar complex is left intact for a more natural appearance. From a prophylactic standpoint, a total mastectomy is generally preferred over a subcutaneous mastectomy because there is less residual breast tissue remaining, which decreases the likelihood that breast cancer will develop in the future. However, prophylactic mastectomy is only one form of breast cancer risk-reduction strategy. It does not provide 100% protection against the development of breast cancer.

PROPHYLACTIC OOPHORECTOMY/SALPINGO-OOPHORECTOMY

Prophylactic oophorectomy is the preventive, surgical removal of the ovaries. Prophylactic salpingo-oophorectomy is the preventive, surgical removal of the fallopian tubes and ovaries. The goal of prophylactic oophorectomy or salpingo-oophorectomy is to prevent the development of ovarian cancer and/or reduce the risk of breast cancer in individuals who are at high risk for these diseases.

Ovarian epithelial carcinoma is one of the most common gynecologic malignancies and the leading cause of death due to gynecologic malignancy. Most individuals are diagnosed after the age of 50, with the greatest risk of ovarian cancer occurring in individuals over the age of 70. The lifetime risk of developing ovarian cancer is 1.7% for the general population. Because of the inadequacies of existing screening techniques, which include pelvic examination, transvaginal ultrasound, and serum CA-125 testing, most cases of ovarian cancer go undiagnosed until the disease is well advanced; survival rates for ovarian cancer are very poor. The etiology of ovarian cancer is uncertain, but increased age, nulliparity, and a family history of the disease confer an increased risk, with family history being the strongest risk factor.

There are three major ovarian cancer syndromes: hereditary breast and ovarian cancer (HBOC), which is caused by mutations in the breast cancer susceptibility genes BRCA1 and BRCA2; site-specific ovarian cancer syndrome; and Lynch syndrome (a combination of breast, ovarian, endometrial, gastrointestinal, and genitourinary cancers), which is associated with hereditary nonpolyposis colorectal cancer (HNPCC). Autosomal dominant inheritance has been shown in some of these mutations, and the lifetime risk for ovarian cancer associated with these syndromes ranges from 5% to over 60%, depending on the population studied. Individuals who have these gene mutations are at risk for other cancers, and the lifetime risk of breast cancer among individuals with a mutation in BRCA1 or BRCA2 approaches 90%. While screening measures for breast cancer generally detect tumors at earlier stages than do ovarian cancer screening measures, no screening test for either breast or ovarian cancer has been shown to decrease cancer risk.

PROPHYLACTIC HYSTERECTOMY

Prophylactic hysterectomy represents a highly effective intervention for mitigating the risk of endometrial cancer in high-risk individuals. The procedure entails surgical removal of the uterus and, when indicated, concurrent excision of additional reproductive organs. Decisions about timing are individualized and based on a thorough evaluation of medical history, reproductive goals, and relevant clinical and pathologic risk factors.

Lynch syndrome, also known as hereditary nonpolyposis colorectal cancer (HNPCC), is an autosomal-dominant inherited condition that substantially increases one’s susceptibility to colon and endometrial cancer. It is caused by pathogenic variants in the mismatch-repair genes MLH1, MSH2, MSH6, and PMS2. Individuals with Lynch syndrome who have a uterus and/or ovaries carry a 40% to 60% lifetime risk of endometrial cancer and a 10% to 12% risk of ovarian cancer, making gynecologic malignancies among the most common “sentinel cancers” in this population. Clinical guidelines therefore support consideration of risk‑reducing hysterectomy, with or without bilateral salpingo‑oophorectomy, after completion of childbearing or when future fertility is no longer desired—particularly for those with MLH1 or MSH2 variants, who face the highest risk.

References

5th International Symposium on Hereditary Breast and Ovarian Cancer, BRCA: Twenty Years of Advances. Current Oncology. 2014;21(2):e358.

American College of Obstetricians and Gynecologists. ACOG Committee Opinion number ​774 (Replaces Committee Opinion Number 620, January 2015), Salpingectomy for Ovarian Cancer Prevention. ​Reaffirmed 2024. Available at: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/04/opportunistic-salpingectomy-as-a-strategy-for-epithelial-ovarian-cancer-prevention. Accessed February 5, 2026.​​​

American College of Obstetricians and Gynecologists; ACOG Committee on Practice Bulletins--Gynecology; ACOG Committee on Genetics; Society of Gynecologic Oncologists. ACOG Practice Bulletin No.182: Hereditary breast and ovarian cancer syndrome. Obstet Gynecol. 2017;130(3):664-665.

American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 89. Elective and risk-reducing salpingo-oophorectomy. Obstet Gynecol. 2008;111(1):231-241.

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Chapman JS, Powell CB, McLennan J, et al. Surveillance of survivors: follow-up after risk-reducing salpingo-oophorectomy in BRCA 1/2 mutation carriers. Gynecol Oncol. 2011;122(2):339-343.

Chen Y, Bancroft E, Ashley S, et al. Baseline and post prophylactic tubal-ovarian surgery CA125 levels in BRCA1 and BRCA2 mutation carriers. Fam Cancer. 2014;13(2):197-203.

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Davies KR, Cantor SB, Brewster AM. Better contralateral breast cancer risk estimation and alternative options to contralateral prophylactic mastectomy. Int J Womens Health. 2015;7181-7187.

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Fakkert IE, Abma EM, Westrik IG, et al. Bone mineral density and fractures after risk-reducing salpingo-oophorectomy in women at increased risk for breast and ovarian cancer. Eur J Cancer. 2015;51(3):400-408.

Fakkert IE, Abma EM, Westrik IG, et al. Bone mineral density and fractures after risk-reducing salpingo-oophorectomy: A cross-sectional study. Int J Gynecol Cancer. 2014;24(9):321-322.

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Igelhart JD, Kaelin CM. Diseases of the breast. In: Townsend CM, Beauchamp DR, Evers MB, et al, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 16th ed. Philadelphia, PA: WB Saunders Co; 2001: 573-580.

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Jatoi I, Parsons HM. Contralateral prophylactic mastectomy and its association with reduced mortality: evidence for selection bias. Breast Cancer Res Treat. 2014;148(2):389-396.

Julian-Reynier C, Bouhnik AD, Mouret-Fourme E, et al. Time to prophylactic surgery in BRCA1/2 carriers depends on psychological and other characteristics. Genet Med. 2010;12(12):801-807.

Kaas R, Verhoef S, Wesseling J, et al. Prophylactic mastectomy in BRCA1 and BRCA2 mutation carriers: very low risk for subsequent breast cancer. Ann Surg. 2010;251(3):488-492.

Kauff ND, Satagopan JM, Rosen ME, et al. Risk-reducing salpingo-oophorectomy in women with a BRCA1 or BRCA2 mutation. N Engl J Med. 2002;346(21):1609-1615.

Kenkhuis MJ, de Bock GH, Elferink PO, et al. Short-term surgical outcome and safety of risk reducing salpingo-oophorectomy in BRCA1/2 mutation carriers. Maturitas. 2010;66(3):310-314.

Khadim MF, Eastwood P, Price J, et al. Multidisciplinary one-stage risk-reducing gynaecological and breast surgery with immediate reconstruction in BRCA-gene carrier women. Eur J Surg Oncol. 2013;39(12):1346-1350.

Kiely BE, Jenkins MA, McKinley JM, et al. Contralateral risk-reducing mastectomy in BRCA1 and BRCA2 mutation carriers and other high-risk women in the Kathleen Cuningham Foundation Consortium for Research into Familial Breast Cancer (kConFab). Breast Cancer Res Treat. 2010;120(3):715-723.

Kim D, Kang E, Hwang E, et al. Factors affecting the decision to undergo risk-reducing salpingo-oophorectomy among women with BRCA gene mutation. Fam Cancer. 2013;12(4):621-628.

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Kwon JS, Tinker A, Pansegrau G, et al. Prophylactic salpingectomy and delayed oophorectomy as an alternative for BRCA mutation carriers. Obstet Gynecol. 2013;121(1):14-24.

Kwong A, Chu AT. What made her give up her breasts: a qualitative study on decisional considerations for contralateral prophylactic mastectomy among breast cancer survivors undergoing BRCA1/2 genetic testing. Asian Pac J Cancer Prev. 2012;13(5):2241-2247.

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Landon G, Stewart J, Deavers M, et al. Peritoneal washing cytology in patients with BRCA1 or BRCA2 mutations undergoing risk-reducing salpingo-oophorectomies: a 10-year experience and reappraisal of its clinical utility. Gynecol Oncol. 2012;125(3):683-686.

Landsbergen KM, Prins JB, Kamm YJ, et al. Female BRCA mutation carriers with a preference for prophylactic mastectomy are more likely to participate an educational-support group and to proceed with the preferred intervention within 2 years. Fam Cancer. 2010;9(2):213-220.

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Muto MG. Risk-reducing bilateral salpingo-oophorectomy in women at high risk of epithelial ovarian and fallopian tubal cancer. In: UpToDate, Goff B (Ed), UpToDate, Waltham, MA. Updated 02/04/2026. Available at: http://www.uptodate.com/contents/risk-reducing-bilateral-salpingo-oophorectomy-in-women-at-high-risk-of-epithelial-ovarian-and-fallopian-tubal-cancer?source=search_result&search=prophylactic+oophorectomy&selectedTitle=1~26. Accessed February 5, 2026.​​

Nair N, Schwartz M, Guzzardi L, et al. Hysterectomy at the time of risk-reducing surgery in BRCA patients. Gynecol Oncol Rep. 2018;26:71-74.

National Cancer Institute (NCI). Cancer Genetics Overview (PDQ®) - Health Professional Version. Updated ​12/02/2025. ​Available at: http://www.cancer.gov/about-cancer/causes-prevention/genetics/overview-pdq#link/_123. Accessed February 5, 2026.​

National Cancer Institute (NCI). Fact Sheet: Surgery to Reduce the Risk of Breast Cancer. ​Updated 01/31/2025. Available at: http://www.cancer.gov/cancertopics/factsheet/Therapy/risk-reducing-surgery. Accessed February 5, 2026.​

National Cancer Institute (NCI). Genetics of Breast and Gynecologic Cancers (PDQ®) - Health Professional Version. Updated 03/06/2025. Available at: http://www.cancer.gov/types/breast/hp/breast-ovarian-genetics-pdq. Accessed February 5, 2026.​​

National Cancer Institute (NCI). Genetics of Colorectal Cancer (PDQ®) - Health Professional Version. Updated ​03/21/2025. Available at: http://www.cancer.gov/types/colorectal/hp/colorectal-genetics-pdq. Accessed February 5, 2026​​. 

National Cancer Institute (NCI). Ovarian, Fallopian Tube, and Primary Peritoneal Cancer Prevention (PDQ®) - Health Professional Version. Updated ​​04/09/2025. Available at: http://www.cancer.gov/types/ovarian/hp/ovarian-prevention-pdq. Accessed February 5, 2026.​

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology - Breast Cancer. ​v.1.2026. [NCCN Web site]. 01/16/2026. Available at: http://www.nccn.org/professionals/physician_gls/PDF/breast.pdf [via subscription only]. Accessed February 5, 2026.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology - Breast Cancer Risk Reduction. v.1.2026. [NCCN Web site]. ​08/29/2025. Available at: http://www.nccn.org/professionals/physician_gls/PDF/breast_risk.pdf [via subscription only]. Accessed February 5, 2026.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology - Breast Cancer Screening and Diagnosis. v.2.2025. [NCCN Web site] ​03/28/2025. Available at: http://www.nccn.org/professionals/physician_gls/PDF/breast-screening.pdf [via subscription only]. Accessed February 5, 2026.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology - Genetic/Familial High-Risk Assessment: Breast and Ovarian. v.2.2026. [NCCN Web site].​ 10/10/2025. Available at: https://www.nccn.org/professionals/physician_gls/pdf/genetics_bop.pdf [via subscription only]. Accessed February 5, 2026.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology - Genetic/Familial High-Risk Assessment: Colorectal. ​v.1.2025.  [NCCN Web site]. ​06/13/2025. Available at: https://www.nccn.org/professionals/physician_gls/pdf/genetics_colon.pdf [via subscription only]. Accessed February 5, 2026.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology - Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer. v.3.2025. [NCCN Web site]. 07/16/2025. Available at: https://www.nccn.org/professionals/physician_gls/pdf/ovarian.pdf [via subscription only]. Accessed February 5, 2026.

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Nisman B, Kadouri L, Allweis T, et al. Increased proliferative background in healthy women with BRCA1/2 haploinsufficiency is associated with high risk for breast cancer. Cancer Epidemiol Biomarkers Prev. 2013;22(11):2110-2115.

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O'Neill SC, Valdimarsdottir HB, Demarco TA, et al. BRCA1/2 test results impact risk management attitudes, intentions, and uptake. Breast Cancer Res Treat. 2010;124(3):755-764.

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Peled AW, Irwin CS, Hwang ES, et al. Total skin-sparing mastectomy in BRCA mutation carriers. Ann Surg Oncol. 2014;21(1):37-41.

Perabo M, Fink V, Gunthner-Biller M, et al. Prophylactic mastectomy with immediate reconstruction combined with simultaneous laparoscopic salpingo-oophorectomy via a transmammary route: a novel surgical approach to female BRCA-mutation carriers. Arch Gynecol Obstet. 2014;289(6):1325-1330.

Pesce C, Liederbach E, Wang C, et al. Contralateral prophylactic mastectomy provides no survival benefit in young women with estrogen receptor-negative breast cancer. Ann Surg Oncol. 2014;21(10):3231-3239.

Pezaro C, James P, McKinley J, et al. The consequences of risk reducing salpingo-oophorectomy: the case for a coordinated approach to long-term follow up post surgical menopause. Fam Cancer. 2012;11(3):403-410.

Pichert G, Jacobs C, Jacobs I, et al. Novel one-stop multidisciplinary follow-up clinic significantly improves cancer risk management in BRCA1/2 carriers. Fam Cancer. 2010;9(3):313-319.

Portnoy DB, Loud JT, Han PK, et al. Effects of False-Positive Cancer Screenings and Cancer Worry on Risk-Reducing Surgery Among BRCA1/2 Carriers. Health Psychol. 2015;34(7):709-717.

Powell CB, Chen LM, McLennan J, et al. Risk-reducing salpingo-oophorectomy (RRSO) in BRCA mutation carriers: experience with a consecutive series of 111 patients using a standardized surgical-pathological protocol. Int J Gynecol Cancer. 2011;21(5):846-851.

Powell CB, Swisher EM, Cass I, et al. Long term follow up of BRCA1 and BRCA2 mutation carriers with unsuspected neoplasia identified at risk reducing salpingo-oophorectomy. Gynecol Oncol. 2013;129(2):364-371.

Primas H, Kroiss R, Kalteis K, et al. Impact of lifestyle factors on preneoplastic changes in prophylactic oophorectomies of BRCA mutation carriers. Eur J Cancer Prev. 2012;21(2):199-204.

Ramon YC, Torres A, Alonso C, et al. Risk factors associated with the occurrence of breast cancer after bilateral salpingo-oophorectomy in high-risk women. Cancer Epidemiol. 2011;35(1):78-82.

Rebbeck TR, Lynch HT, Neuhausen SL, et al. Prevention and Observation of Surgical End Points Study Group. Prophylactic oophorectomy in carriers of BRCA1 or BRCA2 mutations. N Engl J Med. 2002;346(21):1616-1622.

Reitsma W, de Bock GH, Oosterwijk JC, et al. Support of the 'fallopian tube hypothesis' in a prospective series of risk-reducing salpingo-oophorectomy specimens. Eur J Cancer. 2013;49(1):132-141.

Reynolds C, Davidson JA, Lindor NM, et al. Prophylactic and therapeutic mastectomy in BRCA mutation carriers: can the nipple be preserved? Ann Surg Oncol. 2011;18(11):3102-3109.

Rhiem K, Foth D, Wappenschmidt B, et al. Risk-reducing salpingo-oophorectomy in BRCA1 and BRCA2 mutation carriers. Arch Gynecol Obstet. 2011;283(3):623-627.

Rocca WA, Grossardt BR, de Andrade M, et al. Survival patterns after oophorectomy in premenopausal women: a population-based cohort study. Lancet Oncol. 2006;7(10):821-828.

Rosenberg SM, Tracy MS, Meyer ME, et al. Perceptions, knowledge, and satisfaction with contralateral prophylactic mastectomy among young women with breast cancer: a cross-sectional survey. Ann Intern Med. 2013;159(6):373-381.

Roukos DH, Agnanti NJ, Paraskevaidis E, et al. Approaching the dilemma between prophylactic bilateral mastectomy or oophorectomy for breast and ovarian cancer prevention in carriers of BRCA1 or BRCA2 mutations. Ann Surg Oncol. 2002;9(10):941-943.

Rueth NM, McMahon M, Arrington AK, et al. Preoperative risk assessment among women undergoing bilateral prophylactic mastectomy for cancer risk reduction. Ann Surg Oncol. 2011;18(9):2515-2520.

Salhab M, Bismohun S, Mokbel K. Risk-reducing strategies for women carrying BRCA1/2 mutations with a focus on prophylactic surgery. BMC Womens Health. 2010;1028.

Sakorafas GH, Tsiotou AG. Prophylactic mastectomy; evolving perspectives. Eur J Cancer. 2000;36(5):567-578.

Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57(2):75-89.

Schmeler KM, Lynch HT, et al. Prophylactic surgery to reduce the risk of gynecologic cancers in the Lynch Syndrome. N Engl JMed. 2006;354(3):261-269.

Schrag D(1), Kuntz KM, Garber JE, et al. Decision analysis – Effects of prophylactic mastectomy and oophorectomy on life expectancy among women with BRCA1 or BRCA2 mutations. N Engl J Med. 1997;336(20):1465-1671.

Schwartz MD, Isaacs C, Graves KD, et al. Long-term outcomes of BRCA1/BRCA2 testing: risk reduction and surveillance. Cancer. 2012;118(2):510-517.

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Sherman ME, Piedmonte M, Mai PL, et al. Pathologic findings at risk-reducing salpingo-oophorectomy: primary results from Gynecologic Oncology Group Trial GOG-0199. J Clin Oncol. 2014;32(29):3275-3283.

Sidon L, Ingham S, Clancy T, et al. Uptake of risk-reducing salpingo-oophorectomy in women carrying a BRCA1 or BRCA2 mutation: evidence for lower uptake in women affected by breast cancer and older women. Br J Cancer. 2012;106(4):775-779.

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Silva AK, Lapin B, Yao KA, et al. The effect of contralateral prophylactic mastectomy on perioperative complications in women undergoing immediate breast reconstruction: a NSQIP analysis. Ann Surg Oncol. 2015;22(11):3474-3480.

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Skytte AB, Gerdes AM, Andersen MK, et al. Risk-reducing mastectomy and salpingo-oophorectomy in unaffected BRCA mutation carriers: uptake and timing. Clin Genet. 2010;77(4):342-349.

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Coding

CPT Procedure Code Number(s)
19303, 58150, 58180, 58262, 58263, 58291, 58542, 58544, 58552, 58554, 58571, 58573, 58661, 58720, 58940
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
See Attachment A.
HCPCS Level II Code Number(s)
N/A
Revenue Code Number(s)
N/A


​

Coding and Billing Requirements

Policy History

Revisions From MA11.077j: 
10/01/2026Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.​

This policy has been identified for an ICD-10 code update, effective 10/01/2026.

The following ICD-10 codes have been added to Attachment A of this policy: 
QA1.790 Familial cancer syndrome with pathogenic BRCA1 mutation
QA1.791 Familial cancer syndrome with pathogenic BRCA2 mutation
QA1.792 Li Fraumeni syndrome​

Revisions From MA11.077i:
​04/01/2026
​This policy has been reviewed and reissued to communicate the Company's continuing position on prophylactic mastectomy, oopherectomy/salpingo-oopherectomy, and hysterectomy.​
10/01/2025Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.​​

This policy has been identified for an ICD-10 code update, effective 10/01/2025.

The following ICD-10 codes have been added to this policy: 
C50.A0 Malignant inflammatory neoplasm of unspecified breast
C50.A1 Malignant inflammatory neoplasm of right breast
C50.A2 Malignant inflammatory neoplasm of left breast
Z15.05 Genetic susceptibility to malignant neoplasm of fallopian tube(s)
Z40.81 Encounter for prophylactic surgery for removal of ovary(s) for persons without known genetic/familial risk factors
Z40.82 Encounter for prophylactic surgery for removal of fallopian tube(s) for persons without known genetic/familial risk factors
Z80.44 Family history of malignant neoplasm of fallopian tube(s)
Z85.4A Personal history of malignant neoplasm of fallopian tube(s)
Z86.00A Personal history of in-situ neoplasm of the fallopian tube(s)​​​​

Revisions From MA11.077h:
​04/30/2025
​This policy has been reissued in accordance with the Company's annual review process.​
​09/09/2024
This version of the policy will become effective 09/09/2024. 

The following criteria has been added to this policy:
Presence of a PALB2 gene mutation

The following medically necessary criteria have been revised in this policy: 
FROM Ethnicity associated with higher BRCA mutation frequency, such as individuals of Ashkenazi Jewish descent 
TO Belonging to groups that have high prevalence of BRCA variations mainly due to their ancestral decent (e.g., Ashkenazi Jewish)

FROM Individuals who are beyond childbearing age (40 years of age or older) who have been diagnosed with a hereditary ovarian cancer syndrome...
TO Individuals after completion of childbearing who have been diagnosed with a hereditary ovarian cancer syndrome...

The following ICD-10 codes have been added to this policy:
  • D05.01 Lobular carcinoma in situ of right breast
  • D05.02 Lobular carcinoma in situ of left breast
  • D05.11 Intraductal carcinoma in situ of right breast 
  • D05.12 Intraductal carcinoma in situ of left breast
  • D05.8 Other specified type of carcinoma in situ of breast
  • D05.81 Other specified type of carcinoma in situ of right breast
  • D05.82 Other specified type of carcinoma in situ of left breast
  • D05.91 Unspecified type of carcinoma in situ of right breast
  • D05.92 Unspecified type of carcinoma in situ of left breast​
  • Z15.04 Genetic susceptibility to malignant neoplasm of endometrium​

Revisions From MA11.077g:​
​01/01/2024
​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage lines of business. ​
10/01/2023Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.​

This policy has been identified for an ICD-10 code update, effective 10/01/2023.

The following ICD-10 code has been revised from this policy 
  • ​Q85.81 PTEN hamartoma tumor syndrome
The following ICD-10 codes have been added to this policy: 

 

  • R92.30 Dense breasts, unspecified
  • R92.311 Mammographic fatty tissue density, right breast
  • R92.312 Mammographic fatty tissue density, left breast
  • R92.313 Mammographic fatty tissue density, bilateral breasts
  • R92.321 Mammographic fibroglandular density, right breast
  • R92.322 Mammographic fibroglandular density, left breast
  • R92.323 Mammographic fibroglandular density, bilateral breasts
  • R92.331 Mammographic heterogeneous density, right breast
  • R92.332 Mammographic heterogeneous density, left breast
  • R92.333 Mammographic heterogeneous density, bilateral breasts
  • R92.341 Mammographic extreme density, right breast
  • R92.342 Mammographic extreme density, left breast
  • R92.343 Mammographic extreme density, bilateral breasts

Revisions From MA11.077f:​
​06/28/2023
​This policy has been reissued in accordance with the Company's annual review process.​
10/01/2022Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.​

This policy has been identified for an ICD-10 code update, effective 10/01/2022.

The following ICD-10 code has been deleted from this policy 
  • ​Q85.8 Other phakomatoses, not elsewhere classified
The following ICD-10 codes have been added to this policy: 
  • Q85.81 PTEN tumor syndrome
  • Q85.82 Other Cowden syndrome
  • Q85.83 Von Hippel-Lindau syndrome
  • Q85.89 Other phakomatoses, not elsewhere classified​

Revisions From MA11.077e:
04/20/2022This policy has been reissued in accordance with the Company's annual review process.​
​06/16/2021
This policy has been reissued in accordance with the Company's annual review process.​
​07/01/2020
​This policy has been reissued in accordance with the Company's annual review process.​
​01/01/2020
This version of this policy will become effective 01/01/2020.
The following CPT code has been termed from the policy: 19304.​

Revisions From MA11.077d:
10/01/2019This version of the policy will become effective 10/01/2019.
The following ICD-10 codes have been added to the policy: N63.15 and N63.25.

Revisions From MA11.077c:
04/24/2019The policy has been reviewed and reissued to communicate the Company's continuing position on Prophylactic Mastectomy, Oophorectomy/Salpingo-Oophorectomy, and Hysterectomy.
10/01/2017The following ICD-10 Diagnosis code has been deleted from this policy:
    N63 Unspecified lump in breast

The following ICD-10 Diagnosis codes have been added to this policy: N63.0, N63.10, N63.11, N63.12, N63.13, N63.14, N63.20, N63.21, N63.22, N63.23, N63.24, N63.31, N63.32, N63.41, N63.42, Z40.02, Z40.03

Revisions From MA11.077b:
06/21/2017This policy has been reissued in accordance with the Company's annual review process.
08/26/2016The following revisions were made to this policy:

Title
The title of this policy was changed to include Oophorectomy/Salpingo-Oophorectomy, and Hysterectomy.

Description Section
Language was added regarding prophylactic oophorectomy/salpingo-oophorectomy and prophylactic hysterectomy.

Policy Section
Language was added communicating the Company's coverage position for Prophylactic Oophorectomy/Salpingo-Oophorectomy and Prophylactic Hysterectomy.

Coding Table
The following CPT codes were added to this policy: 58150, 58180, 58262, 58263, 58291, 58542, 58544, 58552, 58554, 58571, 58573, 58661, 58720, 58940

The following ICD-10 Diagnosis code was added to this policy: Z80.0

Revisions From MA11.077a:
01/01/2016The following criteria was added to the policy section:

    Individuals are considered to have a high risk for breast cancer when they have one or more of the following:
    • High risk (lifetime risk about 20% or greater) of developing breast cancer as identified by models that are largely defined by family history
    • Li-Fraumeni syndrome, Cowden syndrome, Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative with one of these syndromes
    • Presence of a CDH1 or STK11 gene mutation
All ICD-9 Diagnosis codes were removed from this policy.

The following ICD-10 Diagnosis codes were removed from this policy: C50.011, C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129, C50.211, C50.212, C50.219, C50.221, C50.222, C50.229, C50.311, C50.312, C50.319, C50.321, C50.322, C50.329, C50.411, C50.412, C50.419, C50.421, C50.422, C50.429, C50.511, C50.512, C50.519, C50.521, C50.522, C50.529, C50.611, C50.612, C50.619, C50.621, C50.622, C50.629, C50.811, C50.812, C50.819, C50.821, C50.822, C50.829, C50.911, C50.912, C50.919, C50.921, C50.922, C50.929, D05.00, D05.01, D05.02, D05.10, D05.11, D05.12, D05.80, D05.81, D05.82, D05.90, D05.91, D05.92, T66.xxxA, T66.xxxD, T66.xxxS

The following ICD-10 Diagnosis codes were added to this policy: Q85.8, Q87.89.

Revisions From MA11.077:
01/01/2015This is a new policy.
10/1/2026
10/1/2026
MA11.077
Medical Policy Bulletin
Medicare Advantage
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.