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DESCRIPTIONProphylactic oophorectomy is the preventive, surgical removal of the ovaries. The goal of prophylactic oophorectomy is to prevent the development of ovarian cancer and/or reduce the risk of breast cancer in women 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 women are diagnosed after the age of 50, with the greatest risk of ovarian cancer occurring in women over the age of 70. The lifetime risk of developing ovarian cancer is 1.7% for the general population. Due to 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 and 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 II 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. Women who have these gene mutations are at risk for other cancers, and the lifetime risk of breast cancer among women 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.
When appropriate genetic counseling and an accurate risk assessment has been performed, prophylactic oophorectomy in women with a confirmed BRCA mutation and for women who are verified members of a site-specific ovarian cancer family, after childbearing has been completed or after the age of 35 is considered medically necessary.
Prophylactic oophorectomy in women who are members of HNPCC families is considered investigational due to the lack of evidence involving women with Lynch II Syndrome.
Prophylactic oophorectomy in women with one or more relative with breast and/or ovarian cancer who are not verified members of a site-specific ovarian family or verified BRCA mutation carriers is considered investigational.
Prophylactic oophorectomy in women at average risk is considered investigational.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY3/2003: Approved by Medical Policy Advisory Committee (MPAC)
12/17/2003: Code Reference section updated, CPT code 58900, 58920, 58925, 58943, 58950, 58951, 58952, 58953, 58954, 58960 deleted, ICD-9 procedure code 65.01, 65.09 deleted, ICD-9 diagnosis code 183.0, V16.40 deleted
09/22/2006: Coding updated. ICD9 2006 revisions added to policy
12/31/2008: Policy reviewed, no changes.
08/28/2015: Code Reference section updated for ICD-10. Added ICD-9 diagnosis codes V84.01 and V84.02.
Hayes Medical Technology Directory
ACOG Practice Bulletin, Clinical Management Guidelines for Obstetrician-Gynecologists, Number 7, September 1999
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below ae ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.