Medical Policy

Effective Date:01/01/2003 Title:Cancer Prevention Surgery
Revision Date:01/01/2020 Document:BI235:00
CPT Code(s):19303-19304
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Cancer prevention surgery is surgery done to remove an organ or organs which are believed to be at risk for cancer development. The usual assessment of risk is based on family history and/or genetic testing.

2)    QualChoice recognizes both the trend and the importance of such considerations to individual members who may be affected. This policy is intended to clarify coverage for such surgical procedures.

3)    There is a difference between surgery done in the context of changes in an organ that reflect a pre-cancerous change and surgery done in the absence of any change for the purpose of avoiding the development of cancer.

a)    Once pre-cancerous changes or cancers have been detected, surgical procedures to treat or remove the pre-cancerous or cancerous changes are considered by QualChoice to be a routine part of treatment. These treatments may be subject to preauthorization or review, but they are not the subject of this policy

b)    Surgery that is contemplated in the absence of a cancer and in the absence of any detectable pre-cancerous changes is the subject of this policy.

4)    Most organs are required for vital functions, so removing them for purposes of preventing cancer is not possible. Two organs are frequently considered for removal as a cancer prevention strategy: ovaries and breasts.

5)    Prophylactic oophorectomy and prophylactic mastectomy – the removal of ovaries or breasts for the purpose of preventing cancer – require preauthorization.

Medical Statement

PROPHYLACTIC MASTECTOMY

1)    Breast cancer is the most common non-skin cancer in women and ranks second only to lung cancer as a cause of death.  Although there is no known way to absolutely prevent cancer, strategies to reduce the risk of breast cancer are available for high-risk women.  The major options include primary prevention by chemoprevention or prophylactic mastectomy, and secondary prevention by early detection through screening mammography and clinical or self-examination of the breasts.  Regular screening reduces breast cancer mortality by detecting the disease early, but it cannot prevent the disease. 

2)    Women at high risk include the following:

a)    Those women with a strong family history of breast cancer (see paragraph 5 below).

b)    Those women with inherited mutations in one of two breast cancer susceptibility genes (BRCA1 and BRCA2).

c)    Those women with previous cancer in one breast or biopsies showing lobular carcinoma in situ (LCIS).

d)    Those women with atypical hyperplasia of the breast. 

3)    BRCA inheritance has also been linked to an increased risk for ovarian cancer.  Although ovarian cancer is less common than breast cancer, it is substantially more lethal.   (See the section on prophylactic oophorectomy below.)

4)    Atypical hyperplasia of the breast is not considered an indication for prophylactic mastectomy.

5)    QualChoice will cover either prophylactic mastectomy or tamoxifen chemoprevention for reduction of short-term incidence of breast cancer for the following high-risk patients:

a)    Patients with  BRCA1 or BRCA2 mutation confirmed by genetic testing OR

b)    Three or more affected first or second degree relatives on same side of family, irrespective of age at diagnosis; OR

c)    There are fewer than three affected first or second degree relatives, but ANY of the following is met:

i)     There are multiple primary or bilateral breast cancers in the patient or one family member; OR

ii)    A family member has been identified with a detectable mutation; OR

iii)   There are one or more cases of ovarian cancer at any age, AND one or more members on the same side of the family with breast cancer at any age; OR

iv)   There is breast cancer in a male patient, or in a male relative; OR

v)    The patient is at increased risk for specific mutations due to ethnic background (for instance: Ashkenazi Jewish descent) AND has one or more relatives with breast cancer or ovarian cancer at any age; OR

vi)   The patient was diagnosed with breast cancer at 45 years of age or less.

6)    Tamoxifen chemoprevention may be contraindicated in women with any of the following:

a)    Women thought to be at increased risk for thromboembolism (i.e., a history of thromboembolism, hypertension, diabetes, or cigarette smoking); OR

b)    Women who are pregnant or who are planning to become pregnant ; OR

c)    Premenopausal taking oral contraceptives as a method of birth control.

 

PROPHYLACTIC BILATERAL OOPHORECTOMY

7)    QualChoice covers prophylactic bilateral oophorectomy in patients that have other risk factors including nulliparity, low parity, infertility, early menarche, late menopause, and late first pregnancy, if they meet any ONE of the following criteria:

a)    Patient has completed childbearing and has hereditary ovarian cancer syndrome based on a family pedigree constructed by a physician or genetic counselor.

b)    Patient has personal history of breast cancer and at least one 1st degree relative (e.g., mother, sister, daughter) with a history of ovarian cancer.

c)    Patient has two 1st degree relatives (e.g., mother, sister, daughter) with a history of ovarian cancer.

d)    Patient has one 1st degree relative (e.g., mother, sister, daughter) and one or more 2nd degree relatives (maternal or paternal aunt or grandmother) with ovarian cancer.

e)    Patient has BRCA1 or BRCA2 mutations confirmed by molecular susceptibility testing for breast and/or ovarian cancer.

 

Codes Used In This BI:

 

19303

Mast simple complete

19304

 

Mast subq Deleted code eff 01/01/2020

Limits
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Reference

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47) Kotwall CA. Breast cancer treatment and chemoprevention. Can Fam Physician. 1999;45:1917-1924.

48) Unic I, Stalmeier PF, Verhoef LC, et al. Assessment of the time-tradeoff values for prophylactic mastectomy of women with a suspected genetic predisposition to breast cancer. Med Decis Making. 1998;18(3):268-277.

49) Mann GB, Borgen PI. Breast cancer genes and the surgeon. J Surg Oncol. 1998;67(4):267-274.

50) Grann VR, Panageas KS, Whang W, et al. Decision analysis of prophylactic mastectomy and oophorectomy in BRCA1-positive or BRCA2-positive patients. J Clin Oncol. 1998;16(3):979-985.

51) Schrag D, Kuntz KM, Garber JE, et al. Decision analysis--effects of prophylactic mastectomy and oophorectomy on life expectancy among women with BRCA1 or BRCA2 mutations. N Engl J Med. 1997;336(20):1465-1471.

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63) Schrag D, Kuntz KM, Garber JE, et al. Benefit of prophylactic mastectomy for women with BRCA1 or BRCA2 mutations. JAMA. 2000;283(23):3070-3072.

64) Eisen A, Rebbeck TR, Wood WC, et al. Prophylactic surgery in women with a hereditary predisposition to breast and ovarian cancer. J Clin Oncol. 2000;18(9):1980-1995.

65) Sakorafas GH, Tsiotou AG. Prophylactic mastectomy; evolving perspectives. Eur J Cancer. 2000;36(5):567-578.

66) Solomon JS, Brunicardi CF, Friedman JD. Evaluation and treatment of BRCA-positive patients. Plast Reconstr Surg. 2000;105(2):714-719.

67) Curry P, Fentiman IS. Management of women with a family history of breast cancer. Int J Clin Pract. 1999;53(3):192-196.

68) Bostwick J 3rd, Wood WC. Contra lateral prophylactic mastectomies. Ann Surg Oncol. 1999;6(6):519.

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84) Lu KH Garber JE, Cramer DW, et al. Occult ovarian tumors in women with BRCA1 or BRCA2 mutations undergoing prophylactic oophorectomy. J Clin Oncol. 2000;18(14):2728-2732.

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94) Kauff ND, et al. Risk-reducing salpingo-oophorectomy in women with a BRCA1 or BRCA2 mutation. N Engl J Med. 2002;346:1609-1615.

95) Rebbeck TR, et al. Prophylactic oophorectomy in carriers of BRCA1 or BRCA2 mutations. N Engl J Med 2002;346:1616-1622.

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Application to Products

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD,  EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.