Current national health insurance coverage policies for breast and ovariancancer prophylactic surgery

Background: The efficacy of prophylactic mastectomy and oophorectomy in red ucing breast and ovarian carcinoma has recently been reported in high-risk women. Because cost has become central to medical decision-making, this stu dy was designed to evaluate currently existing coverage policies for these procedures. Methods: A confidential detailed cross-sectional nationwide survey of 481 m edical directors from the American Association of Health Plans, Medicare, a cid Medicaid was conducted. Results: Of the 150 respondents, 65% (n = 97) had 100,000 or more enrolled members and 35% (n = 53) had fewer than 100,000 enrolled members. Only 44% of private plans have specific policies for coverage of prophylactic mastec tomy for a strong family history of breast cancer and 38% of plans for a BR CA mutation. Only 20% of total responding plans had a policy for coverage o f prophylactic oophorectomy under any clinical circumstance. Governmental c arriers were significantly less likely to have any policy for prophylactic surgery (range, 2%-12%) compared with nongovernmental plans (range, 24%-44% ; P < .001). No significant regional differences for coverage policies were identified (P > .05). Conclusions: Significant variations currently exist fur health insurance co verage of prophylactic mastectomy and oophorectomy. As genetic testing beco mes widespread, more uniform policies should be established to enable appro priate high-risk candidates equal access and coverage for these procedures.