INSURANCE ADJUDICATION FAVORING PROPHYLACTIC SURGERY IN HEREDITARY BREAST-OVARIAN CANCER SYNDROME

Insurance payment to cover costs of prophylactic surgery is occasional ly denied to patients who may be at inordinately high risk for heredit ary cancer. We describe a 43-year-old woman from a hereditary breast-o varian cancer (HBOC) family which showed linkage to BRCA1 and who was at inordinately high risk for cancer but who was denied insurance cove rage for prophylactic oophorectomy, despite strong recommendations by her gynecologist and a cancer geneticist-medical oncologist. The insur ance company claimed that the surgery was not medically necessary beca use the woman's condition (hereditary cancer predisposition) was not a n illness. A summary judgment issued by the Douglas County (Nebraska) District Court ruled in favor of the denial decision of Blue Cross/Blu e Shield. But on appeal, the Nebraska Supreme Court offered the conclu sion that the patient did in fact require this prophylactic surgery an d overruled the District Court's decision for denial. The litigation p rovides the basis for this case report and may provide a precedent for insurance coverage for patients at high risk for hereditary forms of cancer. (C) 1995 Academic Press, Inc.