Can Insurance Cover Prophylactic Mastectomy?

I am a 41 year old female with a strong family history of breast and ovarian cancer. My mom was first diagnosed with BrCa at age 30 and contralateral BrCa at 48 years old; she is BrCa1 mutation carrier so are my cousins which are twins and her mom died of ovarian cancer at age 41; their mom is my aunt and my mom's sister.I have had for the past 4 years more than 3 breast biopsies until last year where i came accross with atypia.Can the group insurance cover my prophylactic mastectomy?I live Fl.

Doctor Answers 6

Preventative mastectomy for BRCA 1+ and strong family history

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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.

Nashville Plastic Surgeon
5.0 out of 5 stars 221 reviews

Genetic Testing

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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.

Max Lehfeldt, MD, FACS
Pasadena Plastic Surgeon

Prophylactic Mastectomy and Strong Family History of Breast Cancer

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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

Direct-to-implant reconstruction for BRCA+ prophylactic mastectomy

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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.

Richard Baxter, MD
Seattle Plastic Surgeon
4.9 out of 5 stars 59 reviews

Prophylactic mastectomies

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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.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Breast cancer

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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.

Samir Shureih, MD
Baltimore Plastic Surgeon

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.