Prophylactic (Risk‑Reducing) Mastectomy — Reimbursement/Payment Policy
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Defines University Health Alliance reimbursement policy, coverage criteria, limitations, and administrative requirements (including prior authorization and applicable codes) for prophylactic (risk‑reducing) mastectomy for members and providers.
No material clinical or coverage changes in this revision.
UHA Coverage Criteria for Prophylactic Mastectomy
UHA coverage criteria for prophylactic mastectomy
Covered when ALL of the following criteria and administrative requirements are met:
ALL of the following
ONE OF the following high‑risk criteria must be present:
- Lobular carcinoma in situ.
- Known pathogenic BRCA1 or BRCA2 mutation.
- Another gene mutation associated with high risk (examples: TP53, PTEN, CDH1, STK11).
- High lifetime risk of breast cancer (approximately 20% or greater) as estimated by validated family‑history risk models.
- History of radiation therapy to the chest between ages 10 and 30 years.
ALL of the following
- Extensive mammographic abnormalities (e.g., diffuse calcifications) such that adequate biopsy or excision is impossible; documentation (radiology reports) must support the extent of abnormalities and inability to biopsy/excise.
ALL of the following
- Preoperative counseling by a clinician other than the operating surgeon regarding cancer risk and treatment options (including enhanced surveillance and chemoprevention); documentation of the counseling session and the counselor's credentials is required.
- Informed consent that explicitly addresses increased complication risks (including the potential doubling of complications with contralateral procedures), the possibility that complications may affect adjuvant therapies, and the limited evidence of overall survival benefit except in narrow categories; consent documentation required.
ALL of the following
- Prior authorization is required through UHA administrative processes (submit via UHA online portal); contact UHA to establish portal access as needed.
ALL of the following
- Not covered for other indications not listed above, including contralateral prophylactic mastectomy in women with breast cancer who do not meet high‑risk criteria; discouraged for average‑risk unilateral breast cancer as it is not known to improve health outcomes.
ALL of the following
- Providers should discuss the American Society of Breast Surgeons' position statement with patients considering prophylactic mastectomy.
Applicable Procedure Codes
| 19303 | Mastectomy, simple, complete |
| 19304 | Mastectomy, subcutaneous |
Prior Authorization and Submission Requirements
Prior authorization required; establish portal login
Prior authorization is required before scheduling reimbursement-covered prophylactic mastectomy. Submit the prior authorization request through UHA’s online portal; if your practice does not yet have a portal login, contact UHA at 808-532-4000 to establish one.
- Prior authorization required (administrative guideline IV.A).
- Submit requests via UHA online portal (administrative guideline IV.B).
- If no portal login, call UHA at 808-532-4000 to establish access (administrative guideline IV.B).
Key Definitions: High Risk
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