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Two types of prophylactic mastectomies can be performed; either total (also referred to as simple) mastectomy, in which the intent is to remove the entire breast and nipple areolar complex, and subcutaneous mastectomy, where the nipple areolar complex is left intact for a more natural appearance. While breast tissue is certainly left behind in a subcutaneous mastectomy, residual breast tissue in the axillary tail and skin flaps may be identified after a total mastectomy. However, from a purely prophylactic standpoint, a total mastectomy is generally preferred over a subcutaneous mastectomy because there is less residual breast tissue.

The appropriateness of a prophylactic mastectomy is a complicated risk-benefit analysis that requires estimates of a patient's risk of breast cancer, typically based on the patient's family history of breast cancer and other factors. Two models are most frequently used, the Claus model and the Gail model. The Gail model uses the following five risk factors: age at evaluation, age at menarche, age at first live birth, number of breast biopsies, and number of first-degree relatives with breast cancer.

See Genetic Testing for Hereditary Breast and/or Ovarian Cancer medical policy.

Prophylactic mastectomy may be considered medically necessary in patients with lobular carcinoma in situ.

None

High risk of breast cancer may be defined as 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 before the age of 45 years and one other relative with breast cancer
• One first-degree relative with breast cancer and one or more relatives 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 with ovarian cancer
• Three or more second-degree or third-degree relatives with breast cancer
• One first-degree relative with bilateral breast cancer
• Presence of a BRCA1 or BRCA2 mutation in the patient consistent with a BRCA 1 or 2 mutation in a family member with breast or ovarian cancer
• Presence of a p53 or PTEN mutation
• Received radiation therapy to the chest between the ages of 10 and 30 years

Note: The above definition of high risk is largely adapted from Hartmann

Patients at moderately increased risk of breast cancer may be identified as follows:

• Those 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 breast cancer diagnosed in the opposite breast.  For this policy, increased risk is defined as a lifetime risk of breast cancer of 20% to 25% or greater as identified by models that are largely defined by family history such as the Gail or Claus model.
• Patients with such extensive mammographic abnormalities (i.e., calcifications) that adequate biopsy is impossible.

It is recommended that all candidates for prophylactic mastectomy consider undergoing counseling regarding cancer risks from a health professional skilled in assessing cancer risk other than the operating surgeon. Cancer risk should be assessed by performing a complete family history, use of the Gail or Claus model to estimate the risk of cancer, and discussion of the various treatment options, including increased surveillance or chemoprevention with tamoxifen or raloxifene.

5/14/2002: Code Reference section updated; 173.5, 174.0-174.9, 175.0-175.9, 198.81, 238.3, 239.3, and 611.72 (malignant codes) deleted

1/17/2003: Policy reviewed; no changes based on Hayes report

11/19/2004: Code Reference section updated, ICD-9 procedure code range 85.33-85.36, 85.41-85.44 listed separately, ICD-9 diagnosis code V50.41 "Note: Must be filed in conjunction with one of the diagnosis codes listed above." added

12/27/2006: Code Reference section updated per the 2007 CPT revisions

1/5/2009: Policy reviewed, additional definitions of "high risk of breast cancer" added to the policy 

04/20/2011: Policy description and statement unchanged.  Removed deleted CPT codes 19180 and 19182 from the Code Reference section.

03/27/2012: Policy reviewed. Policy description updated. Deleted outdated references from the Sources section.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes

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