Humana Prophylactic Mastectomy Form

Description

Prophylactic mastectomy, also referred to as risk-reducing mastectomy (RRM), is the surgical removal of one or both breasts, at a time when there is no known breast cancer, in order to decrease future risk of developing breast cancer. The risk of breast cancer may be reduced by 90% or more by a prophylactic mastectomy.

Breast tissue extends from the clavicle (collarbone) to the lower ribs, sternum (breastbone) and the midaxillary line (center of the underarm). Therefore, even with a total mastectomy, it is not feasible to eliminate all breast tissue that may pose a future cancer risk. Most inherited cases of breast cancer are associated with BRCA1 and BRCA2 variants (mutations), although inherited mutations in other genes may also increase the level of risk for developing cancer at a young age. Most females with a BRCA1 or BRCA2 gene mutation will develop breast cancer at some point.

Prophylactic Mastectomy Effective Date: 02/02/2023

Revision Date: 02/02/2023

Review Date: 02/02/2023

Policy Number: HUM-0456-018

Page: 1 of 8

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Even though it cannot be determined with certainty whether the procedure will benefit a particular individual, RRM may add years of longevity to the lifespan.

There are different types of mastectomies, each of which can be performed on one (single) or both (double) breasts.

• Contralateral mastectomy is the removal of both the affected breast and the healthy breast in an individual diagnosed with unilateral (one-sided) breast cancer.
• Total or simple mastectomy removes all of the breast tissue, including the nipple, the areola and the overlying skin, but does not dissect lymph nodes or remove chest muscle tissue beneath the breast. This procedure is considered the preferred option for preventive surgery in females at very high risk for breast cancer.
• A skin-sparing mastectomy (SSM) involves the removal of breast tissue, the nipple and the areola, but leaves the majority of the breast skin intact for use during breast reconstruction. SSM is a type of subcutaneous mastectomy.
• A nipple sparing mastectomy (NSM), also a type of subcutaneous mastectomy, is performed much the same as the SSM but preserves the skin of the nipple and areola. Enough breast tissue may be left behind to require yearly screening mammograms.

For information regarding breast reconstruction following mastectomy, please refer to Breast Reconstruction Medical Coverage Policy.

Coverage Determination

Any state mandates for prophylactic mastectomy take precedence over this medical coverage policy.

Humana members may be eligible under the Plan for prophylactic mastectomy (including contralateral) for the following indications:

• Ethnicity associated with higher mutation frequency (eg, individual of Ashkenazi Jewish descent) with one or more first- second- or third-degree relatives with breast, ovarian or pancreatic cancer at any age; OR

Prophylactic Mastectomy Effective Date: 02/02/2023

Revision Date: 02/02/2023

Review Date: 02/02/2023

Policy Number: HUM-0456-018

Page: 3 of 8

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• History of radiation therapy to the chest prior to age 30; OR
• Known pathogenic or likely pathogenic variant in a breast cancer susceptibility gene (BRCA1/BRCA2, CDH1, PALB2, PTEN, TP53) proven by genetic testing (for information regarding coverage determination/limitations, please refer to Genetic Testing for Breast, Ovarian and Pancreatic Cancer Susceptibility or Genetic Testing for Cancer Susceptibility Medical Coverage Policies); OR
• Personal history of multiple primary or bilateral breast cancer; OR
• Presence of atypical hyperplasia of lobular or ductal origin and/or lobular carcinoma in situ (LCIS) confirmed on biopsy with dense, fibronodular breasts that are mammographically or clinically difficult to evaluate; OR
• Documented family history* indicating increased lifetime breast cancer risk, using a recognized risk assessment tool

*Family history indicative of increased lifetime breast cancer risk generally includes but may not be limited to, having a first-degree relative with breast, ovarian or prostate cancer or one or more first- or second-degree relatives on the same side of the family with multiple types of primary cancer or multiple successive generations of family members with primary breast, fallopian tube, ovarian, pancreatic, peritoneal and/or prostate cancers.

**The USPSTF recognizes the following risk stratification tools for use at the point of care (provider office) to assist in the determination of an individual’s risk: 7- Question Family History Screening Tool, BRCAPRO, International Breast Cancer Intervention Study Instrument (Tyrer-Cuzick), Manchester Scoring System, Ontario Family History Assessment Tool, Pedigree Assessment Tool, Referral Screening Tool.

Coverage Limitations

Humana members may NOT be eligible under the Plan for prophylactic mastectomy for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Prophylactic Mastectomy Effective Date: 02/02/2023

Revision Date: 02/02/2023

Review Date: 02/02/2023

Policy Number: HUM-0456-018

Page: 4 of 8

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Additional information about familial breast cancer may be found from the following websites:

Background

• American Cancer Society
• National Cancer Institute
• National Comprehensive Cancer Network
• National Library of Medicine

Medical Alternatives

Alternatives to prophylactic mastectomy include, but may not be limited to, the following:

• Enhanced screening (more frequent than yearly), involving breast magnetic resonance imaging (MRI) alternating with mammography as an adjunct to clinical breast exam (please refer to Breast Imaging Medical Coverage Policy)
• Frequent monitoring by a physician that includes clinical breast exams and mammograms
• Genetic counseling
• Genetic testing (please refer to Genetic Testing for Breast, Ovarian and Pancreatic Cancer Susceptibility Medical Coverage Policy)
• Prescription drug therapy

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Humana may offer a disease management program for this condition. The member may call the number on his/her identification card to ask about our programs to help manage his/her care.

Prophylactic Mastectomy Effective Date: 02/02/2023

Revision Date: 02/02/2023

Review Date: 02/02/2023

Policy Number: HUM-0456-018

Page: 5 of 8

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled.

Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.