Prophylactic Oophorectomy

POLICY NUMBER

L.7.01.400

DESCRIPTION

Prophylactic 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.

See Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2) .

POLICY

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.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

3/2003: 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.

06/01/2016: Policy number L.7.01.400 added. Policy Guidelines updated to add medically necessary and investigative definitions.

09/29/2017: Code Reference section updated to revise description for ICD-10 diagnosis code Z40.02. Effective 10/01/2017.

01/18/2023: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."

02/14/2024: Policy reviewed; no changes.

03/13/2025: Policy reviewed; no changes.

SOURCE(S)

1. ACOG Practice Bulletin, Clinical Management Guidelines for Obstetrician-Gynecologists, Number 7, September 1999

2. Hayes Medical Technology Directory

CODE REFERENCE

This 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. 

Covered Codes

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