Insurance Coverage of Prophylactic Mastectomies: A National Review of the United States

Elsevier, Clinical Breast Cancer, Volume 23, Issue 2, February 2023, Pages 211-218
Michael Ha MA Cantab MB BChi, Ledibabari M. Ngaage MA Cantab MB BChir, Emily R. Finkelstein MD, Marissa Klein BS, Annie Yanga BS, Shannon M. Colohan Mac, Suliat M. Nurudeen MD, MPH, Julia H. Terhune MD, Sheri Slezak MD, Yvonne M. Rasko MD

Breast cancer is associated with a multitude of risk factors, such as genetic predisposition and mutations, family history, personal medical history, or previous radiotherapy. A prophylactic mastectomy (PM) may be considered a suitable risk-reducing procedure in some cases. However, there are significant discrepancies between national society recommendations and insurance company requirements for PM.

The authors conducted a cross-sectional analysis of insurance policies for a PM. One-hundred companies were selected based on the greatest state enrolment and market share. Their policies were identified through a Web-based search and telephone interviews, and their medical necessity criteria were extracted.

Preauthorized coverage of PMs was provided by 39% of insurance policies (n = 39) and 5 indications were identified. There was consensus amongst these policies to cover a PM for BRCA1/2 mutations (n = 39, 100%), but was more variable for other genetic mutations (15%-90%). Coverage of PM for the remaining indications varied among insurers: previous radiotherapy (92%), pathological changes in the breast (3%-92%), personal history of cancer (64%) and family history risk factors (39%-51%).

There is a marked level of variability in both the indications and medical necessity criteria for PM insurance policies. The decision to undergo a PM must be carefully considered with a patient's care team and should not be affected by insurance coverage status.