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Current National Health Insurance Coverage Policies for Breast and Ovarian Cancer Prophylactic Surgery

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Abstract

Background: The efficacy of prophylactic mastectomy and oophorectomy in reducing breast and ovarian carcinoma has recently been reported in high-risk women. Because cost has become central to medical decision-making, this study was designed to evaluate currently existing coverage policies for these procedures.

Methods: A confidential detailed cross-sectional nationwide survey of 481 edical directors from the American Association of Health Plans, Medicare, and Medicaid was conducted.

Results: Of the 150 respondents, 65% (n 5 97) had 100,000 or more enrolled members and 35% (n 5 53) had fewer than 100,000 enrolled members. Only 44% of private plans have specific policies for coverage of prophylactic mastectomy for a strong family history of breast cancer and 38% of plans for a BRCA mutation. Only 20% of total responding plans had a policy for coverage of prophylactic oophorectomy under any clinical circumstance. Governmental carriers 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 for health insurance coverage of prophylactic mastectomy and oophorectomy. As genetic testing becomes widespread, more uniform policies should be established to enable appropriate high-risk candidates equal access and coverage for these procedures.

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Authors and Affiliations

  1. Department of Surgery, University of California at San Francisco, San Francisco, California

    Henry M. Kuerer MD, PhD, E. Shelley Hwang MD, James P. Anthony MD & Laura J. Esserman MD, MBA

  2. Institute for Health Policy Studies, University of California at San Francisco, San Francisco, California

    R. Adams Dudley MD, MBA & Wade M. Aubry MD

  3. Cancer Risk Program, University of California at San Francisco, San Francisco, California

    Beth Crawford MS

  4. Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030

    Henry M. Kuerer MD, PhD

Authors
  1. Henry M. Kuerer MD, PhD
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  2. E. Shelley Hwang MD
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  3. James P. Anthony MD
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  4. R. Adams Dudley MD, MBA
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  5. Beth Crawford MS
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  6. Wade M. Aubry MD
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  7. Laura J. Esserman MD, MBA
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Kuerer, H.M., Hwang, E.S., Anthony, J.P. et al. Current National Health Insurance Coverage Policies for Breast and Ovarian Cancer Prophylactic Surgery. Ann Surg Oncol 7, 325–332 (2000). https://doi.org/10.1007/s10434-000-0325-1

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  • DOI: https://doi.org/10.1007/s10434-000-0325-1

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