Insurance Coverage of Prophylactic Mastectomies: A National Review of the United States.

BACKGROUND: Breast cancer is associated with a multitude of risk factors, such as genetic predisposition and mutations, family history, personal medical history, or previous radiotherapy. A prophylactic mastectomy (PM) may be considered a suitable risk-reducing procedure in some cases. However, there are significant discrepancies between national society recommendations and insurance company requirements for PM. MATERIALS AND METHODS: The authors conducted a cross-sectional analysis of insurance policies for a PM. One-hundred companies were selected based on the greatest state enrolment and market share. Their policies were identified through a Web-based search and telephone interviews, and their medical necessity criteria were extracted. RESULTS: Preauthorized coverage of PMs was provided by 39% of insurance policies (n = 39) and 5 indications were identified. There was consensus amongst these policies to cover a PM for BRCA1/2 mutations (n = 39, 100%), but was more variable for other genetic mutations (15%-90%). Coverage of PM for the remaining indications varied among insurers: previous radiotherapy (92%), pathological changes in the breast (3%-92%), personal history of cancer (64%) and family history risk factors (39%-51%). CONCLUSION: There is a marked level of variability in both the indications and medical necessity criteria for PM insurance policies. The decision to undergo a PM must be carefully considered with a patient's care team and should not be affected by insurance coverage status.

Contralateral prophylactic mastectomy in the setting of breast cancer diagnosis and their insurance coverage in the United States.

BACKGROUND: Contralateral prophylactic mastectomy (CPM) is more common in the United States than the rest of the world. However, the benefit of this procedure is still under question in many breast cancer scenarios. CPM utilization in the United States is in part dependent on a patient's health insurance coverage of breast oncology surgery and any desired reconstruction. However, there are great discrepancies in the coverage provided by insurers. METHODS: The authors conducted a cross-sectional analysis of insurance policies for a CPM in the setting of diagnosed breast cancer. One hundred companies were selected based on their state enrollment and market share. Their policies were identified through a Web-based search and telephone interviews, and their medical necessity criteria were extracted. RESULTS: Of the 100 companies assessed, 36 (36%) had a policy for CPM. Within those, significantly more provided coverage than denied the procedure (72% vs. 25%, p < 0.0001), with the remainder providing case-by-case coverage. Eleven criteria were identified from preauthorized policies, the most common prerequisite was breast cancer diagnosis under 45 years old (n = 9, 35%). Most policies did not differentiate between gender in their policies (n = 25, 69%), but of those that did, 100% (n = 11) provided coverage for men and women, with 82% (n = 9) requiring further criteria from the female patients. CONCLUSION: The coverage of CPM in the United States varies from complete denial to unrestricted approval. This may be due to conflicting reports in the literature as to the utility of the procedure. The decision to undergo this procedure must be taken with thoughtful consideration and the support of a multidisciplinary approach.

A National Review of Insurance Coverage of Noncancerous Breast Reconstruction.

BACKGROUND: Breast reconstruction is commonly performed for a multitude of noncancerous indications, such as correction of congenital deformities, acquired tissue disease, burns, and trauma. However, breast reconstruction for noncancerous indications is often considered cosmetic or not explicitly mentioned in insurance policies. The goal of this study was to assess variability in insurance coverage of breast reconstruction for noncancerous indications. METHODS: The authors conducted a cross-sectional analysis of 102 US insurance companies, including Medicare and Medicaid, for coverage of breast reconstruction for noncancerous indications (Poland syndrome, fibrocystic breast disease, burns and trauma). Insurance companies were selected based on their state enrollment data and market share. A Web-based search and individual telephone interviews were conducted to identify the policy. Medical necessity criteria were abstracted from publicly available policies. RESULTS: Half of the insurers (49%, n = 50) had no policy for Poland syndrome, 46% (n = 47) had no policy for burns and trauma, and 82% (n = 84) had no policy for fibrocystic breast disease. Fifty-two percent (n = 22) of policies providing coverage for Poland syndrome, 24% (n = 13) of policies providing coverage for burns and trauma, and 58% (n = 7) of policies providing coverage for fibrocystic breast disease had specific, stringent criteria for medical necessity. Thirty-six percent (n = 15) of policies covering Poland syndrome, 47% (n = 26) of policies covering burns and trauma, and 33% (n = 4) of policies covering fibrocystic breast disease include coverage of the contralateral breast. CONCLUSIONS: There is a paucity of publicly available information on insurance coverage of breast reconstruction for noncancerous indications and a lack of consensus between top US insurance companies on what constitutes medical necessity for surgical correction.

Programming of initial steps in bile acid synthesis by breast-feeding vs. formula-feeding in the baboon.

We tested the hypothesis that breast- vs. formula-feeding differentially affects the enzymatic activity of three sterol hydroxylases critical in the initial steps of bile acid formation. Thirty baboons were either breast-fed or formula-fed for the first 14 wk of life before weaning to baboon chow. At 14 and 34 wk of age, liver biopsies were assayed for cholesterol 7alpha-hydroxylase (CYP7A1), 27-hydroxycholesterol-7alpha-hydroxylase (CYP7B1), and cholesterol 27-hydroxylase (CYP27A1). We also determined the kinetics of 3H-27-hydroxycholesterol (27-OHC) turnover in vivo at both ages. At 14 wk of age, hepatic CYP7A1 activity was low but sevenfold higher among formula-fed vs. breast-fed baboons. By 34 wk, CYP7A1 activity had increased nearly 10-fold in both infant diet groups, and the sevenfold difference in CYP7A1 between previously breast- and formula-fed animals persisted. There were no differences in CYP7B1 activities between infant diet groups at either 14 or 34 wk of age although the activity increased in both groups by about 50% from 14 to 34 wk. CYP27A1 activity also increased between 14 and 34 wk of age, and, compared with CYP7A1, relatively small differences in CYP27A1 activity due to infant diet were observed at each age. Plasma 27-OHC turnover had a half-time of 2-4 min. We had previously reported that after weaning, the total bile acid synthesis rate was higher among baboons that were formula-fed than among breast-fed animals. The present results suggest that this difference is most likely due to significantly higher CYP7A1 activity among formula-fed vs. breast-fed animals.