Can Insurance Cover Prophylactic Mastectomy?

Thank you for your question.  I recommend you see a health care provider in your area who specializes in breast, preferably at a comprehensive breast center. If you haven't already had it, genetic testing will likely be recommended.  Based on the results and your calculated risk for developing breast cancer, your providers can discuss the possibility of prophylactic mastectomies with you.  If you seek prophylactic mastectomies, the typical process would be for your surgeon/surgeon's office to formally request pre-approval from your insurance company for the mastectomies prior to the surgery to ensure that it is a covered benefit under your plan.  You also could be referred to see a plastic surgeon to discuss the possibilities of breast reconstruction which would also need to be submitted to insurance for pre-approval.  In general, this is the typical process but it is important for you to see your doctor and discuss this directly with him/her. He/she should be able to give you much more detailed information especially about any unique requirements for your state. I hope this helps give you a general idea but you need to see your doctor to discuss the process specifically.

I am sure you know that the answer depends in part on testing to see if you are BRCA positive, but if there is biopsy-proven atypia I would expect your insurer to cover it in any case. You should also consult with a plastic surgeon who can do immediate reconstruction. In situations like yours, it often works out very well for the surgeon to do a nipple-sparing mastectomy, and the plastic surgeon then uses an implant and an Alloderm internal bra for total reconstruction in one stage.

It is unfortunate to hear that your family has such a strong history of breast and ovarian cancer.  I would strongly recommend that you get Genetic Testing for the BRCA mutation.  This will direct you as to what you should do.  If you are positive for BRCA, then I would recommend bilateral prophylactic mastectomies (which should be covered by insurance).  In addition, you can also contact a plastic and reconstructive surgeon who can do breast reconstruction at the same time as your mastectomies (this will also be covered by insurance).  It can include breast implants, tissue expanders, or autologous tissue reconstruction.

Something else to consider is the need for prophylactic oophorectomies (removal of your ovaries).  This should be covered by insurance as well and can be done at the same time as the other surgeries most times.  

Please make sure you see a board-certified plastic surgeon if you would like to consider breast reconstruction.

It has been my experience that patients with a strong family history of breast cancer and/or the BRCA gene generally get their prophylactic mastectomy and reconstruction covered by their insurance.  Please check with your Human Resources department and/or your insurance provider to get confirmation.   And visit with a board certified plastic surgeon in your area who can refer you to a skilled mastectomy breast surgeon to development an oncoplastic immediate reconstruction plan.  Best of luck.

Dr. Basu

First, you need to have genetic testing and counseling to see if you have inherited the gene. If so, then your insurance company should cover your surgery.

With that strong family history, you need genetic councelling and testing. As for coverage for prophylactic mastectomy, you need to check with your insurance company. some insurance have denied that. Also ask them if they will cover the reconstruction.