Risk-Reducing (Prophylactic) Mastectomy

This policy covers risk‑reducing (prophylactic) mastectomy — removal of breast tissue to lower future breast cancer risk — for specified high‑risk groups such as individuals with known pathogenic BRCA1/BRCA2 or other high‑penetrance gene variants (e.g., TP53, PTEN, PALB2, CDH1, STK11), those with lobular carcinoma in situ (LCIS), people with an elevated lifetime risk (~≥20%) by validated risk models, prior chest radiation at ages 10–30, extensive mammographic abnormalities, and contralateral prophylaxis for patients with cancer in the opposite breast. Coverage is limited to the listed indications and is subject to the member’s benefit plan and required documentation (confirmatory genetic/pathology reports and clinical notes); prophylactic mastectomy is considered investigational for unlisted indications, is not a treatment for active malignancy, and transgender/gender‑affirming procedures are excluded under a separate policy.

"Lobular carcinoma in situ (LCIS)"