Aetna BRCA Testing, Prophylactic Mastectomy, Prophylactic Oophorectomy coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• PROPHYLACTIC MASTECTOMY — medically necessary for breast cancer risk reduction in women meeting ANY ONE of the following: women diagnosed with breast cancer at age 45 or younger.
• PROPHYLACTIC MASTECTOMY (ONE of): women at increased risk due to ethnic background (e.g., Ashkenazi Jewish descent) with one or more relatives with breast cancer or epithelial ovarian cancer at any age.
• PROPHYLACTIC MASTECTOMY (ONE of): women carrying germline mutations in CDH1, TP53, PTEN, or PALB2 genes.
• PROPHYLACTIC MASTECTOMY (ONE of): women with BRCA1 or BRCA2 mutations confirmed by molecular susceptibility testing.
• PROPHYLACTIC MASTECTOMY (ONE of): women who received chest radiation between ages 10 and 30 (e.g., for Hodgkin disease).
• PROPHYLACTIC MASTECTOMY (ONE of): women with a first- or second-degree male relative with breast cancer.
• PROPHYLACTIC MASTECTOMY (ONE of): women with multiple primary or bilateral breast cancers in a first- or second-degree blood relative.
• PROPHYLACTIC MASTECTOMY (ONE of): women with multiple primary or bilateral breast cancers (personal history).
• PROPHYLACTIC MASTECTOMY (ONE of): women with one or more epithelial ovarian cancer cases AND one or more first- or second-degree blood relatives on the same family side with breast cancer.
• PROPHYLACTIC MASTECTOMY (ONE of): women with three or more affected first- or second-degree blood relatives on the same family side, irrespective of age at diagnosis.
• PROPHYLACTIC MASTECTOMY (ONE of): women with atypical hyperplasia (lobular or ductal) and/or lobular carcinoma in situ confirmed on biopsy, with dense, fibronodular breasts that are mammographically or clinically difficult to evaluate.
• PROPHYLACTIC MASTECTOMY — acceptable surgical methods include: skin-sparing mastectomy (when there is no skin cancer involvement).
• PROPHYLACTIC MASTECTOMY — acceptable surgical method: nipple-sparing mastectomy (when there is no nipple-areola complex cancer involvement).
• PROPHYLACTIC MASTECTOMY — acceptable surgical method: two-stage procedure with oncoplastic breast reduction followed by prophylactic mastectomy and breast reconstruction (for large-breasted women).
• PROPHYLACTIC BILATERAL OOPHORECTOMY / SALPINGO-OOPHORECTOMY — medically necessary in selected women with epithelial ovarian carcinoma risk factors (nulliparity, low parity, infertility, early menarche, late menopause, late first pregnancy) who meet ANY ONE of the following: women beyond child-bearing age (40+ years) diagnosed with hereditary epithelial ovarian cancer syndrome based on family pedigree assessed by a genetic counselor or physician competent in determining autosomal dominant inheritance pattern.
• PROPHYLACTIC BILATERAL OOPHORECTOMY / SALPINGO-OOPHORECTOMY (ONE of): women with two first-degree relatives (mother, sister, daughter) with a history of epithelial ovarian cancer.
• PROPHYLACTIC BILATERAL OOPHORECTOMY / SALPINGO-OOPHORECTOMY (ONE of): women with a personal history of breast cancer AND at least one first-degree relative with a history of epithelial ovarian cancer.
• PROPHYLACTIC BILATERAL OOPHORECTOMY / SALPINGO-OOPHORECTOMY (ONE of): women with BRCA1 or BRCA2 germline mutations confirmed by molecular susceptibility testing.
• PROPHYLACTIC BILATERAL OOPHORECTOMY / SALPINGO-OOPHORECTOMY (ONE of): women carrying germline mutations in BRIP1, RAD51C, RAD51D, MLH1, or MSH2 genes.
• PROPHYLACTIC BILATERAL OOPHORECTOMY / SALPINGO-OOPHORECTOMY (ONE of): women with one first-degree relative AND one or more second-degree relatives (maternal/paternal aunt, grandmother, niece) with a history of epithelial ovarian cancer.
• HYSTERECTOMY WITH PROPHYLACTIC OOPHORECTOMY: prophylactic hysterectomy should be performed in conjunction with oophorectomy in women from families with Lynch syndrome I. For women with breast-ovarian cancer syndrome, site-specific ovarian cancer syndrome, or epithelial ovarian cancer family history who choose prophylactic oophorectomy, the decision to add hysterectomy depends on the woman's attitudes regarding hormone replacement and potential morbidity.
• GERMLINE MULTIGENE PANEL TESTING for moderate-to-high penetrance breast/epithelial ovarian cancer susceptibility genes — medically necessary ONCE PER LIFETIME for persons who meet one or more NCCN testing criteria for high-penetrance breast cancer susceptibility genes (NCCN CRIT-2, 4, 5, 6); the panel must include at minimum high-penetrance susceptibility genes for breast cancer. Reference: NCCN Genetic/Familial High-Risk Assessment: Breast, Ovarian, and Pancreatic Guidelines (CPB 0227 defers to NCCN rather than restating the detailed family-history criteria in full).

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 81162·PA verdict·Rate
• 81163·PA verdict·Rate
• 81164·PA verdict·Rate
• 81165·PA verdict·Rate
• 81166·PA verdict·Rate
• 81167·PA verdict·Rate
• 81212·PA verdict·Rate
• 81215·PA verdict·Rate
• 81216·PA verdict·Rate
• 81217·PA verdict·Rate
• 81432·PA verdict·Rate
• 19301·PA verdict·Rate
• 19303·PA verdict·Rate
• 58661·PA verdict·Rate
• 58700·PA verdict·Rate
• 58720·PA verdict·Rate
• 58940·PA verdict·Rate

Documentation required

• An 'Aetna Breast and Ovarian Cancer Susceptibility Gene Testing Prior Authorization Form' for Breast and Ovarian Cancer Susceptibility Gene Molecular Testing is to be sent along with the Laboratory's Test Requisition Form to Aetna for precertification.
• Documentation of the specific cancer diagnosis in the proband(s) and pertinent medical records may be required prior to authorization.
• A summary indicating how this testing will change the immediate medical care of the member must be included with the Prior Authorization request.
• Family history documented with a 3-generation pedigree, prior pathology reports, and physicians' notes.
• For testing of a non-Aetna family member: a copy of the denial letter from the non-Aetna member's benefit plan is required; Aetna may also request a certificate of coverage from the non-member's insurance if the denial letter fails to specify the basis for non-coverage, the denial is based on a plan exclusion, or the test was denied as not medically necessary and the medical information does not clarify significant benefit to the non-member.

Frequently asked questions

When does Aetna cover BRCA Testing, Prophylactic Mastectomy, Prophylactic Oophorectomy (CPT 81162), and what gets it denied?

Aetna CPB 0227 covers prophylactic (risk-reducing) mastectomy and prophylactic bilateral oophorectomy/salpingo-oophorectomy for women who meet specific high-risk criteria (e.g., BRCA1/BRCA2 or other high-penetrance gene mutations, strong personal or family history of breast/ovarian cancer, prior chest radiation), and covers germline multigene panel BRCA testing once per lifetime when NCCN high-penetrance testing criteria are met. Genetic testing requires precertification (the lab cannot run the specimen until the test is precertified), and a range of services are excluded as experimental or not medically necessary (e.g., elective salpingectomy in low-risk women, prophylactic mastectomy in men or for benign breast conditions, testing under age 18, and panels with RNA analysis/polygenic risk scores). Coverage criteria include: PROPHYLACTIC MASTECTOMY — medically necessary for breast cancer risk reduction in women meeting ANY ONE of the following: women diagnosed with breast cancer at age 45 or younger.; PROPHYLACTIC MASTECTOMY (ONE of): women at increased risk due to ethnic background (e.g., Ashkenazi Jewish descent) with one or more relatives with breast cancer or epithelial ovarian cancer at any age.; PROPHYLACTIC MASTECTOMY (ONE of): women carrying germline mutations in CDH1, TP53, PTEN, or PALB2 genes.; PROPHYLACTIC MASTECTOMY (ONE of): women with BRCA1 or BRCA2 mutations confirmed by molecular susceptibility testing.; PROPHYLACTIC MASTECTOMY (ONE of): women who received chest radiation between ages 10 and 30 (e.g., for Hodgkin disease).; PROPHYLACTIC MASTECTOMY (ONE of): women with a first- or second-degree male relative with breast cancer.; PROPHYLACTIC MASTECTOMY (ONE of): women with multiple primary or bilateral breast cancers in a first- or second-degree blood relative.; PROPHYLACTIC MASTECTOMY (ONE of): women with multiple primary or bilateral breast cancers (personal history).; PROPHYLACTIC MASTECTOMY (ONE of): women with one or more epithelial ovarian cancer cases AND one or more first- or second-degree blood relatives on the same family side with breast cancer.; PROPHYLACTIC MASTECTOMY (ONE of): women with three or more affected first- or second-degree blood relatives on the same family side, irrespective of age at diagnosis.; PROPHYLACTIC MASTECTOMY (ONE of): women with atypical hyperplasia (lobular or ductal) and/or lobular carcinoma in situ confirmed on biopsy, with dense, fibronodular breasts that are mammographically or clinically difficult to evaluate.; PROPHYLACTIC MASTECTOMY — acceptable surgical methods include: skin-sparing mastectomy (when there is no skin cancer involvement).; PROPHYLACTIC MASTECTOMY — acceptable surgical method: nipple-sparing mastectomy (when there is no nipple-areola complex cancer involvement).; PROPHYLACTIC MASTECTOMY — acceptable surgical method: two-stage procedure with oncoplastic breast reduction followed by prophylactic mastectomy and breast reconstruction (for large-breasted women).; PROPHYLACTIC BILATERAL OOPHORECTOMY / SALPINGO-OOPHORECTOMY — medically necessary in selected women with epithelial ovarian carcinoma risk factors (nulliparity, low parity, infertility, early menarche, late menopause, late first pregnancy) who meet ANY ONE of the following: women beyond child-bearing age (40+ years) diagnosed with hereditary epithelial ovarian cancer syndrome based on family pedigree assessed by a genetic counselor or physician competent in determining autosomal dominant inheritance pattern.; PROPHYLACTIC BILATERAL OOPHORECTOMY / SALPINGO-OOPHORECTOMY (ONE of): women with two first-degree relatives (mother, sister, daughter) with a history of epithelial ovarian cancer.; PROPHYLACTIC BILATERAL OOPHORECTOMY / SALPINGO-OOPHORECTOMY (ONE of): women with a personal history of breast cancer AND at least one first-degree relative with a history of epithelial ovarian cancer.; PROPHYLACTIC BILATERAL OOPHORECTOMY / SALPINGO-OOPHORECTOMY (ONE of): women with BRCA1 or BRCA2 germline mutations confirmed by molecular susceptibility testing.; PROPHYLACTIC BILATERAL OOPHORECTOMY / SALPINGO-OOPHORECTOMY (ONE of): women carrying germline mutations in BRIP1, RAD51C, RAD51D, MLH1, or MSH2 genes.; PROPHYLACTIC BILATERAL OOPHORECTOMY / SALPINGO-OOPHORECTOMY (ONE of): women with one first-degree relative AND one or more second-degree relatives (maternal/paternal aunt, grandmother, niece) with a history of epithelial ovarian cancer.; HYSTERECTOMY WITH PROPHYLACTIC OOPHORECTOMY: prophylactic hysterectomy should be performed in conjunction with oophorectomy in women from families with Lynch syndrome I. For women with breast-ovarian cancer syndrome, site-specific ovarian cancer syndrome, or epithelial ovarian cancer family history who choose prophylactic oophorectomy, the decision to add hysterectomy depends on the woman's attitudes regarding hormone replacement and potential morbidity.; GERMLINE MULTIGENE PANEL TESTING for moderate-to-high penetrance breast/epithelial ovarian cancer susceptibility genes — medically necessary ONCE PER LIFETIME for persons who meet one or more NCCN testing criteria for high-penetrance breast cancer susceptibility genes (NCCN CRIT-2, 4, 5, 6); the panel must include at minimum high-penetrance susceptibility genes for breast cancer. Reference: NCCN Genetic/Familial High-Risk Assessment: Breast, Ovarian, and Pancreatic Guidelines (CPB 0227 defers to NCCN rather than restating the detailed family-history criteria in full).. Applies to 17 codes: 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 81432, 19301, 19303, 58661, 58700, 58720, 58940. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Prior authorization status is code-specific; this CPB is not an exact authorization source for every covered code. Check the Aetna precertification list or PA lookup for the exact code and plan context. Documentation: An 'Aetna Breast and Ovarian Cancer Susceptibility Gene Testing Prior Authorization Form' for Breast and Ovarian Cancer Susceptibility Gene Molecular Testing is to be sent along with the Laboratory's Test Requisition Form to Aetna for precertification.; Documentation of the specific cancer diagnosis in the proband(s) and pertinent medical records may be required prior to authorization.; A summary indicating how this testing will change the immediate medical care of the member must be included with the Prior Authorization request.; Family history documented with a 3-generation pedigree, prior pathology reports, and physicians' notes.; For testing of a non-Aetna family member: a copy of the denial letter from the non-Aetna member's benefit plan is required; Aetna may also request a certificate of coverage from the non-member's insurance if the denial letter fails to specify the basis for non-coverage, the denial is based on a plan exclusion, or the test was denied as not medically necessary and the medical information does not clarify significant benefit to the non-member. Policy exclusions and limitations: EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN: elective salpingectomy for ovarian cancer prevention in women at low hereditary risk.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN: measurement of blood lead level as a marker of increased ovarian cancer risk in BRCA1 carriers.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN: multigene panel tests that include RNA analysis or polygenic risk scores (e.g., Invitae Multi-Cancer +RNA Panel, Invitae Common Hereditary Cancers +RNA Panel).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN: prophylactic mastectomy for men with BRCA mutations or family history of breast cancer.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN: prophylactic mastectomy for women with CHEK2 gene mutation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN: testing for germline FANCG variants for breast and ovarian cancer predisposition.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN: prophylactic mastectomy for diabetic mastopathy.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN: prophylactic mastectomy for fibrocystic breast disease.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN: prophylactic mastectomy for pseudo-angiomatous stromal hyperplasia (PASH).; NOT MEDICALLY NECESSARY: unilateral oophorectomy at the time of hysterectomy when both ovaries are present.; NOT MEDICALLY NECESSARY: breast and ovarian cancer susceptibility gene testing for individuals less than 18 years of age.; NOT COVERED / LIMITATION: asymptomatic individuals with a family history meeting testing criteria but without an identified causative variant should not rely solely on BRCA1 or BRCA2 testing; current standard of care requires analysis of moderate-to-high penetrance genes.; NOT COVERED: testing performed primarily for the medical management of family members who are not Aetna members — UNLESS ALL of the following are met: (a) the information is needed to adequately assess risk in the Aetna member; (b) the information will be used in the immediate care plan of the Aetna member; AND (c) the non-Aetna member's benefit plan will not cover the test (a copy of the denial letter is required).; NOT COVERED — gene not covered for breast/ovarian cancer testing: BARD1 gene.; NOT COVERED — gene/complex not covered for breast/ovarian cancer testing: Mre11 (MRN) complex.; NOT COVERED — gene not covered for breast/ovarian cancer testing: MUTYH gene (see CPB 0140).; NOT COVERED — gene not covered for breast/ovarian cancer testing: NBN gene.; NOT COVERED: overly broad multigene panels that exceed the genes recommended by NCCN Genetic/Familial High-Risk Assessment (Breast, Ovarian, and Pancreatic).; NOT COVERED: panel testing that includes RNA analysis for pan-cancer susceptibility or polygenic risk scores. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Does Aetna require prior authorization for BRCA Testing, Prophylactic Mastectomy, Prophylactic Oophorectomy?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Prior authorization status is code-specific; this CPB is not an exact authorization source for every covered code. Check the Aetna precertification list or PA lookup for the exact code and plan context. Documentation: An 'Aetna Breast and Ovarian Cancer Susceptibility Gene Testing Prior Authorization Form' for Breast and Ovarian Cancer Susceptibility Gene Molecular Testing is to be sent along with the Laboratory's Test Requisition Form to Aetna for precertification.; Documentation of the specific cancer diagnosis in the proband(s) and pertinent medical records may be required prior to authorization.; A summary indicating how this testing will change the immediate medical care of the member must be included with the Prior Authorization request.; Family history documented with a 3-generation pedigree, prior pathology reports, and physicians' notes.; For testing of a non-Aetna family member: a copy of the denial letter from the non-Aetna member's benefit plan is required; Aetna may also request a certificate of coverage from the non-member's insurance if the denial letter fails to specify the basis for non-coverage, the denial is based on a plan exclusion, or the test was denied as not medically necessary and the medical information does not clarify significant benefit to the non-member.

What does Aetna exclude for BRCA Testing, Prophylactic Mastectomy, Prophylactic Oophorectomy?

Policy exclusions and limitations: EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN: elective salpingectomy for ovarian cancer prevention in women at low hereditary risk.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN: measurement of blood lead level as a marker of increased ovarian cancer risk in BRCA1 carriers.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN: multigene panel tests that include RNA analysis or polygenic risk scores (e.g., Invitae Multi-Cancer +RNA Panel, Invitae Common Hereditary Cancers +RNA Panel).; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN: prophylactic mastectomy for men with BRCA mutations or family history of breast cancer.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN: prophylactic mastectomy for women with CHEK2 gene mutation.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN: testing for germline FANCG variants for breast and ovarian cancer predisposition.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN: prophylactic mastectomy for diabetic mastopathy.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN: prophylactic mastectomy for fibrocystic breast disease.; EXPERIMENTAL/INVESTIGATIONAL/UNPROVEN: prophylactic mastectomy for pseudo-angiomatous stromal hyperplasia (PASH).; NOT MEDICALLY NECESSARY: unilateral oophorectomy at the time of hysterectomy when both ovaries are present.; NOT MEDICALLY NECESSARY: breast and ovarian cancer susceptibility gene testing for individuals less than 18 years of age.; NOT COVERED / LIMITATION: asymptomatic individuals with a family history meeting testing criteria but without an identified causative variant should not rely solely on BRCA1 or BRCA2 testing; current standard of care requires analysis of moderate-to-high penetrance genes.; NOT COVERED: testing performed primarily for the medical management of family members who are not Aetna members — UNLESS ALL of the following are met: (a) the information is needed to adequately assess risk in the Aetna member; (b) the information will be used in the immediate care plan of the Aetna member; AND (c) the non-Aetna member's benefit plan will not cover the test (a copy of the denial letter is required).; NOT COVERED — gene not covered for breast/ovarian cancer testing: BARD1 gene.; NOT COVERED — gene/complex not covered for breast/ovarian cancer testing: Mre11 (MRN) complex.; NOT COVERED — gene not covered for breast/ovarian cancer testing: MUTYH gene (see CPB 0140).; NOT COVERED — gene not covered for breast/ovarian cancer testing: NBN gene.; NOT COVERED: overly broad multigene panels that exceed the genes recommended by NCCN Genetic/Familial High-Risk Assessment (Breast, Ovarian, and Pancreatic).; NOT COVERED: panel testing that includes RNA analysis for pan-cancer susceptibility or polygenic risk scores. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT