Breast and Ovarian Cancer Susceptibility Gene Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy

Aetna considers prophylactic mastectomy medically necessary for high‑risk women — specifically those diagnosed with breast cancer at ≤45 years, women of high‑risk ethnic background (e.g., Ashkenazi Jewish) with a family history of breast or epithelial ovarian cancer, women with confirmed pathogenic germline mutations (BRCA1/2, CDH1, TP53, PTEN, PALB2), and women who received chest radiation between ages 10–30. It is considered experimental/investigational for other indications (e.g., diabetic mastopathy, fibrocystic disease, PASH) and in men (except contralateral removal in men with breast cancer), elective salpingectomy in low hereditary‑risk women is investigational, unilateral oophorectomy at hysterectomy is not medically necessary, and genetic testing is not medically necessary for individuals under 18.

"Evidence and prevalence for some genes (CHEK2, BARD1, RAD51D, PALB2) vary by population and cohort; some variants (rare germline mutations, missense) may have uncertain significance limiting immedi..."